Reference Request Form

STRICTLY CONFIDENTIAL APPLICATION FORM

Candidate's name

fill in Name of Candidate

Referee Name

Your Name

Your Position

Company name where you worked with client

Address Company

Date From

Date to

Candidates job title

Reason for Leaving

Are you aware of any suspicious proceedings, Policy investigations or disciplinary action on-going or on file? *

Are you aware of suspicion

Yes No

If yes to last question, add details here

Has the candidate's honesty and integrity ever been brought into

Level of performance

Level of Performance

Excellent Good Satisfactory Poor

Additional comment

I declare that to the best of my knowledge the information I have given in this reference is complete and accurate .

Signature

Phone Number

Date