Employment Reference Request Form

XApplicant Name: Florin Mindru

Post Applied for: Staff Nurse

The person named above has applied for employment with Circle and has given their consent for us to approach you for a
reference. Please answer the following questions honestly and as accurately as possible. Individuals have a right under the
Data Protection Act 1998 to see copies of references received about them and we cannot therefore guarantee the complete
confidentiality of any reference received.

Company applicant worked for: SC VISAMED SA – MEDICAL COMPANY

Dates of employment (Please use exact dates)

Were you the applicant’s Line Manager? If no, please confirm YES
your relationship with the applicant

What was the applicant's job title? REGISTERED NURSE

Nature of work (specific duties and responsibilities)

Did the applicant have supervisory responsibility? NO

Did the applicant have any disciplinary warnings during their NO

last 12 months' employment with your company? If yes, please
comment on the nature of warnings

Are you aware of any recent/outstanding allegations that were NO

made against the applicant that relate to any safeguarding
issues/referrals (including any referrals to the DBS)? If yes,
please provide details

Reasons for leaving employment BETTER JOB OPORTUNITY

Would you re-employ the applicant? YES

What is your assessment of the following elements in relation Excellent Good Fair Poor
to the applicant?
Attendance/ punctuality X
Comments:

Working relationships X
Comments:

Skills demonstrated (in line with role requirements) X

Comments:

Leadership Qualities (if applicable to role) X

Comments:

Please comment further, if possible, on the applicant's suitability for employment into the post

Referee Name: ADRIAN CICORTAS Company Stamp

*alternatively
Job title: ADMINISTRATOR, G.P. please send via
company email or
Signature: enclose copy of
company
Date: 09.07.2018 letterhead

If you you have any queries, please contact the HR Team at HR@circlebath.co.uk
Please return this form either by email to HR@circlebath.co.uk or by post to HR Team, Foxcote Ave, Peasedown St. John, Bath BA2
8SQ
 Employment Reference Request Form

If you you have any queries, please contact the HR Team at HR@circlebath.co.uk
Please return this form either by email to HR@circlebath.co.uk or by post to HR Team, Foxcote Ave, Peasedown St. John, Bath BA2
8SQ