Name*

Email Address*

Address Line 1*

Address Line 2

Address Line 3

Postcode*

Applicant's Name (person for whom you are giving reference) *

Company Name*

Your position (if former employer)*

Please state capacity in which you know the applicant i.e. friend or employer *

Please comment on his/her suitability to work as a caregiver:

If former employer, please confirm applicant's dates of employment and position held within your organisation, if applicable:

If former employer, please state reason for leaving, if applicable:

Trustworthy Trustworthy Good Average Poor

Punctuality Punctuality Good Average Poor

Attitude Attitude Good Average Poor

Reliability Reliability Good Average Poor

If former employer, would you re-employ this person? If former employer, would you re-employ this person? Yes No

If No, please state why?

Telephone Number - so we can call you to verify the reference *