| Name of employee / prospective employee: |
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| Reference supplied by: |
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| Company: |
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| Did the applicant work for your organisation? |
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| Start date: |
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| Leaving date: |
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| What is/was the applicant's job title with your organisation? |
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| Salary open leaving/current salary: |
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| What are/were the applicant's main job duties? |
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| Does/Did the applicant have supervisory responsibility for other staff? |
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| Does/Did the applicant have any responsibility for recruitment, appraisal, discipline or dismissal? |
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| Does/Did the applicant have any responsibility for money, materials or goods? |
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| Does/Did the applicant have any responsibility for computer operations or computer programming |
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| What is your assessment of the following elements in relation to the applicant? |
| Quality of work |
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| Quantity of work |
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| Quality of customer service |
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| Ability to work without supervision |
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| Working relationships |
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| Do/Did you find the applicant to be honest and trustworthy? |
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| Do/Did you find the applicant to be reliable in carrying out his/her duties? |
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| Is/Was the applicant's time-keeping satisfactory? |
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| Does/Did the applicant have any disciplinary warnings during his/her last 12 months' employment with your organisation? |
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| If the applicant has left, what was the reason for the applicant leaving your organisation? |
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| Would you re-employ the applicant? |
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