Reference Request Form

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Nova Healthcare Service Ltd
The Charter Building
Charter Place
Uxbridge, UB8 1JG
01895 450 620
07701057551
admin@novahc.co.uk
www.novahc.co.uk

Reference Request Form

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Referral Information

Applicant Name *

Position Applied for *

Referee Details

Employer Name *

Position Held *

Company Name *

Company Name, Shop Name, Institute Name

Capacity in which you know the above

Please confirm if you are related to the above. *

Yes
No

Employee Details

Position Held *

Start Date of Employment

Start Month *

Start Year *

Reason for Leaving *

End Date of Employment

End Month *

End Year *

No of Days Sickness in the last 12 months *

Are there any current warning on the applicant's record? *

Yes
No

Is the applicant currently under any investigation for any matter? *

Yes
No

Are you aware of any recent / outstanding allegation that were made against the applicant that related to any safeguarding issues / referrals? *

Yes
No

(including any referrals to the Disclosure and Barring Service or Independent Safeguarding Authority)

If Yes to any of the above, please provide dates and details *

Please rate the applicant on the following by ticking the box for each statement:

Ability *

Very Poor
Poor
Average
Good
Excellent

Cleanliness *

Very Poor
Poor
Average
Good
Excellent

Conduct *

Very Poor
Poor
Average
Good
Excellent

Timekeeping *

Very Poor
Poor
Average
Good
Excellent

Attitude to Colleagues *

Very Poor
Poor
Average
Good
Excellent

Trustworthy *

Very Poor
Poor
Average
Good
Excellent

Is there anything else you feel we should know about this person that is relevant to this post?

Are you aware of any reason why we should not employ the applicant? *

YES
NO

If yes, please supply details

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I consent to having this website store my submitted information so they can respond to my inquiry.

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