Personal Reference Form In line with the Health and Social Care Act, 2008 Regulation 19 Schedule 3 Declaration : *Yes, I agree with the privacy policy and terms and conditions. It is Chelmscare’s policy to obtain a written reference for prospective applicants prior to confirming their employment. We would be most grateful if you comment on the applicant’s appropriateness for the role, they have applied for by completing the “reference” form below. This will assist us in assessing the applicant’s suitability and progress their job application further. Please be assured that all information is kept in the strictest confidence. Please note that as to protect the public the post for which the application has been made is exempt from Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the exemption order, 1975. It is not therefore in any way contrary to the act to reveal any information you have concerning conviction, including those which would otherwise be considered spent. Any information will of course be kept in strict confidence and used only in consideration of the suitability of this applicant for the position stated.PART A :Date of Issue : *Name: *Phone : *0 / 11Email AddressPART B :Please answer the following questionsIn your opinion is the applicant suitable for the position applied for ? *YesNoIs the applicant an honest and trustworthy individual ? *YesNoIn your opinion, is the applicant reliable and punctual ? *YesNoThis field is required.To your knowledge, is the applicant in good health ? *YesNoTo your knowledge, has the applicant been referred to any Safeguarding Authority as a result of misconduct involving either a child or a vulnerable adult ? *YesNoIf you have ticked "YES" to any the above questions, please provide additional information :0 / 500Please add any remark that you think may be relevant to our decision as whether we should employ the applicant.0 / 500Declaration : *I confirm that, as far as I am aware , the information i have provided above is true and accurate. I understand that information provided will be kept in strict confidence and used only in consideration of the suitability of this applicant for the position stated. Yes, I agree with the privacy policy and terms and conditions.E-Signature *Start signing your signature hereYour browser does not support e-Signature field.Full Name : *Position : * Date : *Submit Application