Please choose the type of reference?
About you (Referee)
Your name
Your relationship to applicant
Business name (Professional reference only)
Phone number
About the applicant
Name of applicant
Please confirm the applicants most recent Job title:
Please confirm the applicant’s employment dates, from and to:
How many days sickness has the applicant had over the past 12 months and how many episodes:
HIs the applicant currently under any investigations for any matter?: (if Yes, give details)
Are you aware of any recent / outstanding allegations that were made against the applicant that relate to safeguarding issues:
The applicant has applied for the position in our Medical Team. Are there any additional comments you wish to make about the applicant and their suitability fore the role they have applied for.
The applicant has applied for the position in our Medical Team, please provide any details about the applicants suitability for this role?
Please check this box to confirm you are the named person above (referee) and this information is correct
Referee name:
Referee email address:
