Reference Form23 - Southcare Homes Group

careers

Always looking for talented people to join our family.

Please fill in the following reference form to help new ones join the Southcare family.

reference request form

2. Name of Applicant

3. Position applied for

4. In what capacity do you know the applicant?

5. Date employed/known from

Date employed/known to

6. Please give brief details of of the applicant's duties whilst in your employment

7. Why did the applicant leave your employment? (if applicable)

16. How many day's ill health or unauthorised absence has the applicant taken in the last 12 months?

17. Would you re-employ the applicant?

17a. If no, please state why

18. At the time the applicant left your employment were they subject to any formal warnings?

18a. If yes, please state why

19. The position applied for comes under ‘Adult Social Care’ as defined in the Care Standards Act 2000, and for the purposes of carrying out a regulated activity pursuant to the Health and Social Care Act 2008; as a result please advise if you have referred the above named individual to the ISA

20. Please advise if you have referred the above named to their professional body or association e.g. NMC

20a. If yes, please state why

21. Any other comments:

First Name

Surname

Position

Company

Email Address of Referee

Date

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reference request form

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