Personal Reference Form

Personal Reference Request Form

Name of person you are providing a reference for:

How long have you known this person?

Date from:

Date To:

In what capacity do you know the individual? i.e. employer / colleague / friend:

Are you related to this person?

Yes

Please give brief details about how you know this person:

Do you believe the individual to be strictly honest, conscientious and discreet:

Yes

Do you know of any factors concerning the individual which might cause their fitness for working with young children to be questioned:

Yes

If Yes, please give further details:

The above information is correct to the best of my knowledge and belief.

Name:

Email Address:

Address:

Telephone Number:

Date: