Reference Request – Thema Healthcare

Reference Request Form

Thank you for taking the time to complete this Reference Request Form for Thema Healthcare. We appreciate your support and cooperation in providing accurate information. Your response will be treated confidentially and used solely to assist our recruitment and compliance checks.

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PROFILE

Applicant Name *

FirstLast

Date of birth *

EMPLOYMENT HISTORY

Job title *

Start date *

Leaving date *

In what capacity do you know the applicant? *If "Other", please describe the circumstances *

SKILLS

Referring to the job description, please describe the applicant’s ability to undertake their rolePlease inform us of any disciplinary actions that might have been taken against the applicant:Would you re-employ the applicant?If NO, please indicate why *To your knowledge, has the applicant ever been convicted of a criminal offence (subject to Rehabilitation of Offenders Act 1974 Provisions)? *If YES, please give details: *

Please rate the applicant on the following characteristics. *

	Excellent	Good	Average	Poor
Communication	ExcellentCommunication Excellent	GoodCommunication Good	AverageCommunication Average	PoorCommunication Poor
Ability	ExcellentAbility Excellent	GoodAbility Good	AverageAbility Average	PoorAbility Poor
Character	ExcellentCharacter Excellent	GoodCharacter Good	AverageCharacter Average	PoorCharacter Poor
Conduct	ExcellentConduct Excellent	GoodConduct Good	AverageConduct Average	PoorConduct Poor
Attitude	ExcellentAttitude Excellent	GoodAttitude Good	AverageAttitude Average	PoorAttitude Poor
Loyalty	ExcellentLoyalty Excellent	GoodLoyalty Good	AverageLoyalty Average	PoorLoyalty Poor
Co-operation	ExcellentCo-operation Excellent	GoodCo-operation Good	AverageCo-operation Average	PoorCo-operation Poor
Ability to work with others	ExcellentAbility to work with others Excellent	GoodAbility to work with others Good	AverageAbility to work with others Average	PoorAbility to work with others Poor
Trustworthy	ExcellentTrustworthy Excellent	GoodTrustworthy Good	AverageTrustworthy Average	PoorTrustworthy Poor
Hardworking	ExcellentHardworking Excellent	GoodHardworking Good	AverageHardworking Average	PoorHardworking Poor
Punctual	ExcellentPunctual Excellent	GoodPunctual Good	AveragePunctual Average	PoorPunctual Poor

Please select all characteristics that you believe describe the applicant.

Do you have any other information regarding this application, which you believe, should be known to us as prospective employers?

DETAILS OF REFEREE:

Reference Name *

FirstLast

Reference Email *Position *

Company Address *

Address Line 1Address Line 2CityState / Province / RegionPostal CodeCountry

Reference Phone *

Company Name *

Date

Signature *

Clear Signature
Are you happy for us to contact you about the information you have provided? *