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024 7692 0269 Paul@reviverise.co.uk
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  • For Referees Only

Reference Request Form

Revive Rise Complex Home Care · Nurse-Led Professional Care Services

  • Confidential
RR
Revive Rise
Nurse-Led Professional Care Services
📞 024 7692 0269 www.reviverise.co.uk paul@reviverise.co.uk
Referee Details
Name of Referee *
Referee name is required
Work Address of Referee *
At least address line 1 is required
Subject
Reference Request for *
Applicant name is required
Dear Sir or Madam

The above named person has applied to our organisation for the post of:

Position applied for is required

and has named you as one of their referees. The applicant has agreed that we may approach you in order to obtain a reference and I would be grateful if you would complete the reference form below.


All reference forms submitted will be treated as confidential and will not be shared with the applicant or external parties. Please let me know if you require any additional details to facilitate this process. Thank you for your time and support.

Section A — Relationship to Applicant
In what capacity do you know the applicant? *
Please select how you know the applicant
How long have you known the applicant? *
Please select how long you have known the applicant
Was the applicant employed by your organisation? *
Please select an option
Do you consider them honest and trustworthy? *
Please select an option
Section B — Performance & Character Ratings
Conduct *
Please rate the applicant's conduct
Punctuality *
Please rate the applicant's punctuality
How well did this employee work on their own initiative? *
Please rate the applicant's initiative
How well did this employee relate to work designated by Supervisors, Managers, etc.? *
Please rate the applicant's response to supervisors
How well did this employee work as part of a team? *
Please rate the applicant's teamwork
How well did this employee adapt to change? *
Please rate the applicant's adaptability
Would you re-employ this applicant? *
Please select an option
Section C — General Comments
Section D — Confirmation & Signature
Signature Instruction: In the signature field below, please type your full legal name instead of providing a handwritten or digital signature. Your typed name will serve as your formal confirmation.
Print name is required
Date is required
Signature (typed name) is required

    Application Form

    Position Applied For:

    Location:

    Section 1: Personal Details

    1. Full Name:

    Title (Mr/Mrs/Miss/Ms/Other):

    First Name:

    Last Name:

    2. Address:

    Address Line 1:

    Address Line 2:

    Town/City:

    Postcode:

    3. Contact Details:

    Phone Number:

    Email Address:

    4. Date of Birth:

    (Required for right-to-work checks and DBS compliance.)

    5. National Insurance Number:

    (Required for payroll and tax purposes.)

    6. Do you have the right to work in the UK?

    YesNo

    (Proof of right to work will be required, e.g., passport, visa, or other documentation.)

    Section 2 : Equality and Diversity Monitoring

    Revive Rise is committed to promoting equality and diversity. This information is for monitoring purposes only and will not affect your application.

    1. Gender:

    MaleFemaleNon-binaryPrefer not to say

    2. Ethnicity:

    WhiteMixed/Multiple Ethnic GroupsAsian/Asian BritishBlack/African/Caribbean/Black BritishOther Ethnic GroupPrefer not to say

    3. Do you consider yourself to have a disability?

    YesNoPrefer not to say

    (Revive Rise is a Disability Confident employer and will make reasonable adjustments to support your application.)

    4. Do you have any criminal convictions, cautions or reprimands, bind-overs or have you been given a warning for a criminal offence?

    YesNo

    5. Do you currently have criminal charges pending or are you under a criminal investigation?

    YesNo

    6. Have you ever been disqualified from working with children or vulnerable adults, or are sanctions imposed on you by a regulatory body?

    YesNo

    If your answer to any of the above questions is ‘Yes’, please provide details below.

    If you are providing additional details, please mark your application as “PRIVATE AND CONFIDENTIAL FOR THE ATTENTION OF THE HR MANAGER” (either on the envelope or in the subject of the email).

    Section 3: Employment History

    1. Current/Most Recent Employer:

    Employer Name:

    Job Title:

    Dates of Employment: From To

    Reason for Leaving:

    2. Previous Employment:

    Employer Name:

    Job Title:

    Dates of Employment: From To

    Reason for Leaving:

    3. Previous Employment:

    Employer Name:

    Job Title:

    Dates of Employment: From To

    Reason for Leaving:

    4. Previous Employment:

    Employer Name:

    Job Title:

    Dates of Employment: From To

    Reason for Leaving:

    5. Gaps in Employment:

    Please explain any gaps in your employment history.


    Section 4: Qualifications and Training

    1. Relevant Qualifications:

    Qualification:

    Institution:

    Date Achieved:

    2. Relevant Qualifications:

    Qualification:

    Institution:

    Date Achieved:

    3. Relevant Qualifications:

    Qualification:

    Institution:

    Date Achieved:

    4. Relevant Qualifications:

    Qualification:

    Institution:

    Date Achieved:

    5. Care-Related Training:

    Training Course:

    Date Completed:

    6. Care-Related Training:

    Training Course:

    Date Completed:

    7. Care-Related Training:

    Training Course:

    Date Completed:

    8. Care-Related Training:

    Training Course:

    Date Completed:

    9. Do you hold a valid driving license?

    YesNo

    10. Do you have access to a vehicle?

    YesNo

    Section 5: Skills and Experience

    1. Please describe your experience in domiciliary care or a similar role:

    2. What skills do you possess that make you suitable for this role?

    3. How would you handle challenging situations with clients?

    Section 6: References

    Please provide two people who we may contact for a reference on your suitability for the role. One must be your most recent line manager or supervisor, and the second should also be a previous manager/supervisor. Please ask your referees for permission to give their details before submitting your application.

    1. Reference 1:

    Name:

    Relationship to You:

    Contact Number:

    Email Address:

    2. Reference 2:

    Name:

    Relationship to You:

    Contact Number:

    Email Address:

    Section 7: Declaration

    1. Disclosure and Barring Service (DBS) Check:

    (This role requires an enhanced DBS check. Do you consent to this?)

    YesNo

    2. Declaration:*


    I confirm that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in the withdrawal of any job offer or disciplinary action, including dismissal. I consent to Revive Rise processing my personal data in accordance with GDPR 2018 for the purposes of recruitment and employment.

    Section 8: Additional Information

    1. Is there anything else you would like to tell us about your application?