Applicant Reference Form Applicant Reference Request Form Reference in respect of? (name of applicant)(Required)Role or post applied for:(Required)Date commenced employment/volunteering with you(Required) MM slash DD slash YYYY Date ending employment/volunteering with you(Required) MM slash DD slash YYYY Length of time you have known them:(Required)Capacity in which employed/known:(Required)Main duties:(Required)Salary or wage rate:(Required)Date of leaving:(Required) MM slash DD slash YYYY Attendance record: (Number of days of absence in the last two years (excluding annual leave))(Required)Please provide reasons for absence:(Required)Suitability for work with children and young people(Required)Are you aware of any reason why this person might not be suitable to work with children?(Required)Are you aware of any previous disciplinary action taken against this person where there were concerns relating to children's safety or protection? If so, please give details(Required)Are you aware of any current investif=gations or of any disciplinary sanctions, which remain against this person? This may or may not be related to children's safety and protection. If so, please give details:(Required)QualitiesPlease comment on the applicant’s qualities in relation to the following:Honesty(Required)PoorAverageGoodExcellentReliability(Required)PoorAverageGoodExcellentPunctuality(Required)PoorAverageGoodExcellentAbility to work as part of a team(Required)PoorAverageGoodExcellentAbility to prioritise workload(Required)PoorAverageGoodExcellentWhere relevant to the role, understanding and knowledge of child protection and children's safety issues:(Required)Where relevant to the role, please comment on the applicant's suitability and overall ability to work with children:(Required)Would you re-employ?(Required) Yes No Please add any further information or comments that you feel are relevant to the applicant's proposed new role:(Required)Signature(Required)Print Name(Required)Organisation/Company(Required)Position(Required)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country