midviewhealth.agencyportal.co.uk
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52.25.193.195
Public Scan
Submitted URL: https://u10231366.ct.sendgrid.net/ls/click?upn=-2BF2zK09RdOlrBOQfTVfnk4q5KE2GZGqIumdGzOFCdwQUyCqIRlPJ21HMy7kWF0ENUX7OlX82sINHvsGOA...
Effective URL: https://midviewhealth.agencyportal.co.uk/candidate/referenceform/:reference2/:648ca7b965539a46f7fbecde-1687266183495
Submission: On July 05 via manual from GB — Scanned from GB
Effective URL: https://midviewhealth.agencyportal.co.uk/candidate/referenceform/:reference2/:648ca7b965539a46f7fbecde-1687266183495
Submission: On July 05 via manual from GB — Scanned from GB
Form analysis 1 forms found in the DOM
GET #
<form novalidate="" action="#" method="get" class="av-invalid">
<div class="section-divder">
<div class="card-header">
<h4 class="card-title mb-0">Referee Details</h4>
</div>
<div class="card-body">
<div class="row">
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="refereefirstname" class="">First name</label><input name="refereefirstname" required="" id="refereefirstname" type="text" class="is-untouched is-pristine av-valid form-control" value="Kesiena "></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="refereelastname" class="">Last name</label><input name="refereelastname" required="" id="refereelastname" type="text" class="is-untouched is-pristine av-valid form-control" value="Aaron-Efe"></div>
</div>
<div class="position-relative phone-box col-12 col-md-6"><label class="">Phone</label>
<div class="intl-tel-input allow-dropdown" style="width: 100%;">
<div class="flag-container">
<div class="selected-flag" tabindex="0" title="United Kingdom: +44">
<div class="iti-flag gb"></div>
<div class="iti-arrow"></div>
</div>
<ul class="country-list hide">
<li class="country preferred" data-dial-code="1" data-country-code="us">
<div class="flag-box">
<div class="iti-flag us"></div>
</div><span class="country-name">United States</span><span class="dial-code">+1</span>
</li>
<li class="country highlight preferred" data-dial-code="44" data-country-code="gb">
<div class="flag-box">
<div class="iti-flag gb"></div>
</div><span class="country-name">United Kingdom</span><span class="dial-code">+44</span>
</li>
<div class="divider"></div>
<li class="country" data-dial-code="93" data-country-code="af">
<div class="flag-box">
<div class="iti-flag af"></div>
</div><span class="country-name">Afghanistan (افغانستان)</span><span class="dial-code">+93</span>
</li>
<li class="country" data-dial-code="355" data-country-code="al">
<div class="flag-box">
<div class="iti-flag al"></div>
</div><span class="country-name">Albania (Shqipëri)</span><span class="dial-code">+355</span>
</li>
<li class="country" data-dial-code="213" data-country-code="dz">
<div class="flag-box">
<div class="iti-flag dz"></div>
</div><span class="country-name">Algeria (الجزائر)</span><span class="dial-code">+213</span>
</li>
<li class="country" data-dial-code="1684" data-country-code="as">
<div class="flag-box">
<div class="iti-flag as"></div>
</div><span class="country-name">American Samoa</span><span class="dial-code">+1684</span>
</li>
<li class="country" data-dial-code="376" data-country-code="ad">
<div class="flag-box">
<div class="iti-flag ad"></div>
</div><span class="country-name">Andorra</span><span class="dial-code">+376</span>
</li>
<li class="country" data-dial-code="244" data-country-code="ao">
<div class="flag-box">
<div class="iti-flag ao"></div>
</div><span class="country-name">Angola</span><span class="dial-code">+244</span>
</li>
<li class="country" data-dial-code="1264" data-country-code="ai">
<div class="flag-box">
<div class="iti-flag ai"></div>
</div><span class="country-name">Anguilla</span><span class="dial-code">+1264</span>
</li>
<li class="country" data-dial-code="1268" data-country-code="ag">
<div class="flag-box">
<div class="iti-flag ag"></div>
</div><span class="country-name">Antigua and Barbuda</span><span class="dial-code">+1268</span>
</li>
<li class="country" data-dial-code="54" data-country-code="ar">
<div class="flag-box">
<div class="iti-flag ar"></div>
</div><span class="country-name">Argentina</span><span class="dial-code">+54</span>
</li>
<li class="country" data-dial-code="374" data-country-code="am">
<div class="flag-box">
<div class="iti-flag am"></div>
</div><span class="country-name">Armenia (Հայաստան)</span><span class="dial-code">+374</span>
</li>
<li class="country" data-dial-code="297" data-country-code="aw">
<div class="flag-box">
<div class="iti-flag aw"></div>
</div><span class="country-name">Aruba</span><span class="dial-code">+297</span>
</li>
<li class="country" data-dial-code="61" data-country-code="au">
<div class="flag-box">
<div class="iti-flag au"></div>
</div><span class="country-name">Australia</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="43" data-country-code="at">
<div class="flag-box">
<div class="iti-flag at"></div>
</div><span class="country-name">Austria (Österreich)</span><span class="dial-code">+43</span>
</li>
<li class="country" data-dial-code="994" data-country-code="az">
<div class="flag-box">
<div class="iti-flag az"></div>
</div><span class="country-name">Azerbaijan (Azərbaycan)</span><span class="dial-code">+994</span>
</li>
<li class="country" data-dial-code="1242" data-country-code="bs">
<div class="flag-box">
<div class="iti-flag bs"></div>
</div><span class="country-name">Bahamas</span><span class="dial-code">+1242</span>
</li>
<li class="country" data-dial-code="973" data-country-code="bh">
<div class="flag-box">
<div class="iti-flag bh"></div>
</div><span class="country-name">Bahrain (البحرين)</span><span class="dial-code">+973</span>
</li>
<li class="country" data-dial-code="880" data-country-code="bd">
<div class="flag-box">
<div class="iti-flag bd"></div>
</div><span class="country-name">Bangladesh (বাংলাদেশ)</span><span class="dial-code">+880</span>
</li>
<li class="country" data-dial-code="1246" data-country-code="bb">
<div class="flag-box">
<div class="iti-flag bb"></div>
</div><span class="country-name">Barbados</span><span class="dial-code">+1246</span>
</li>
<li class="country" data-dial-code="375" data-country-code="by">
<div class="flag-box">
<div class="iti-flag by"></div>
</div><span class="country-name">Belarus (Беларусь)</span><span class="dial-code">+375</span>
</li>
<li class="country" data-dial-code="32" data-country-code="be">
<div class="flag-box">
<div class="iti-flag be"></div>
</div><span class="country-name">Belgium (België)</span><span class="dial-code">+32</span>
</li>
<li class="country" data-dial-code="501" data-country-code="bz">
<div class="flag-box">
<div class="iti-flag bz"></div>
</div><span class="country-name">Belize</span><span class="dial-code">+501</span>
</li>
<li class="country" data-dial-code="229" data-country-code="bj">
<div class="flag-box">
<div class="iti-flag bj"></div>
</div><span class="country-name">Benin (Bénin)</span><span class="dial-code">+229</span>
</li>
<li class="country" data-dial-code="1441" data-country-code="bm">
<div class="flag-box">
<div class="iti-flag bm"></div>
</div><span class="country-name">Bermuda</span><span class="dial-code">+1441</span>
</li>
<li class="country" data-dial-code="975" data-country-code="bt">
<div class="flag-box">
<div class="iti-flag bt"></div>
</div><span class="country-name">Bhutan (འབྲུག)</span><span class="dial-code">+975</span>
</li>
<li class="country" data-dial-code="591" data-country-code="bo">
<div class="flag-box">
<div class="iti-flag bo"></div>
</div><span class="country-name">Bolivia</span><span class="dial-code">+591</span>
</li>
<li class="country" data-dial-code="387" data-country-code="ba">
<div class="flag-box">
<div class="iti-flag ba"></div>
</div><span class="country-name">Bosnia and Herzegovina (Босна и Херцеговина)</span><span class="dial-code">+387</span>
</li>
<li class="country" data-dial-code="267" data-country-code="bw">
<div class="flag-box">
<div class="iti-flag bw"></div>
</div><span class="country-name">Botswana</span><span class="dial-code">+267</span>
</li>
<li class="country" data-dial-code="55" data-country-code="br">
<div class="flag-box">
<div class="iti-flag br"></div>
</div><span class="country-name">Brazil (Brasil)</span><span class="dial-code">+55</span>
</li>
<li class="country" data-dial-code="246" data-country-code="io">
<div class="flag-box">
<div class="iti-flag io"></div>
</div><span class="country-name">British Indian Ocean Territory</span><span class="dial-code">+246</span>
</li>
<li class="country" data-dial-code="1284" data-country-code="vg">
<div class="flag-box">
<div class="iti-flag vg"></div>
</div><span class="country-name">British Virgin Islands</span><span class="dial-code">+1284</span>
</li>
<li class="country" data-dial-code="673" data-country-code="bn">
<div class="flag-box">
<div class="iti-flag bn"></div>
</div><span class="country-name">Brunei</span><span class="dial-code">+673</span>
</li>
<li class="country" data-dial-code="359" data-country-code="bg">
<div class="flag-box">
<div class="iti-flag bg"></div>
</div><span class="country-name">Bulgaria (България)</span><span class="dial-code">+359</span>
</li>
<li class="country" data-dial-code="226" data-country-code="bf">
<div class="flag-box">
<div class="iti-flag bf"></div>
</div><span class="country-name">Burkina Faso</span><span class="dial-code">+226</span>
</li>
<li class="country" data-dial-code="257" data-country-code="bi">
<div class="flag-box">
<div class="iti-flag bi"></div>
</div><span class="country-name">Burundi (Uburundi)</span><span class="dial-code">+257</span>
</li>
<li class="country" data-dial-code="855" data-country-code="kh">
<div class="flag-box">
<div class="iti-flag kh"></div>
</div><span class="country-name">Cambodia (កម្ពុជា)</span><span class="dial-code">+855</span>
</li>
<li class="country" data-dial-code="237" data-country-code="cm">
<div class="flag-box">
<div class="iti-flag cm"></div>
</div><span class="country-name">Cameroon (Cameroun)</span><span class="dial-code">+237</span>
</li>
<li class="country" data-dial-code="1" data-country-code="ca">
<div class="flag-box">
<div class="iti-flag ca"></div>
</div><span class="country-name">Canada</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="238" data-country-code="cv">
<div class="flag-box">
<div class="iti-flag cv"></div>
</div><span class="country-name">Cape Verde (Kabu Verdi)</span><span class="dial-code">+238</span>
</li>
<li class="country" data-dial-code="599" data-country-code="bq">
<div class="flag-box">
<div class="iti-flag bq"></div>
</div><span class="country-name">Caribbean Netherlands</span><span class="dial-code">+599</span>
</li>
<li class="country" data-dial-code="1345" data-country-code="ky">
<div class="flag-box">
<div class="iti-flag ky"></div>
</div><span class="country-name">Cayman Islands</span><span class="dial-code">+1345</span>
</li>
<li class="country" data-dial-code="236" data-country-code="cf">
<div class="flag-box">
<div class="iti-flag cf"></div>
</div><span class="country-name">Central African Republic (République centrafricaine)</span><span class="dial-code">+236</span>
</li>
<li class="country" data-dial-code="235" data-country-code="td">
<div class="flag-box">
<div class="iti-flag td"></div>
</div><span class="country-name">Chad (Tchad)</span><span class="dial-code">+235</span>
</li>
<li class="country" data-dial-code="56" data-country-code="cl">
<div class="flag-box">
<div class="iti-flag cl"></div>
</div><span class="country-name">Chile</span><span class="dial-code">+56</span>
</li>
<li class="country" data-dial-code="86" data-country-code="cn">
<div class="flag-box">
<div class="iti-flag cn"></div>
</div><span class="country-name">China (中国)</span><span class="dial-code">+86</span>
</li>
<li class="country" data-dial-code="61" data-country-code="cx">
<div class="flag-box">
<div class="iti-flag cx"></div>
</div><span class="country-name">Christmas Island</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="61" data-country-code="cc">
<div class="flag-box">
<div class="iti-flag cc"></div>
</div><span class="country-name">Cocos (Keeling) Islands</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="57" data-country-code="co">
<div class="flag-box">
<div class="iti-flag co"></div>
</div><span class="country-name">Colombia</span><span class="dial-code">+57</span>
</li>
<li class="country" data-dial-code="269" data-country-code="km">
<div class="flag-box">
<div class="iti-flag km"></div>
</div><span class="country-name">Comoros (جزر القمر)</span><span class="dial-code">+269</span>
</li>
<li class="country" data-dial-code="243" data-country-code="cd">
<div class="flag-box">
<div class="iti-flag cd"></div>
</div><span class="country-name">Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)</span><span class="dial-code">+243</span>
</li>
<li class="country" data-dial-code="242" data-country-code="cg">
<div class="flag-box">
<div class="iti-flag cg"></div>
</div><span class="country-name">Congo (Republic) (Congo-Brazzaville)</span><span class="dial-code">+242</span>
</li>
<li class="country" data-dial-code="682" data-country-code="ck">
<div class="flag-box">
<div class="iti-flag ck"></div>
</div><span class="country-name">Cook Islands</span><span class="dial-code">+682</span>
</li>
<li class="country" data-dial-code="506" data-country-code="cr">
<div class="flag-box">
<div class="iti-flag cr"></div>
</div><span class="country-name">Costa Rica</span><span class="dial-code">+506</span>
</li>
<li class="country" data-dial-code="225" data-country-code="ci">
<div class="flag-box">
<div class="iti-flag ci"></div>
</div><span class="country-name">Côte d’Ivoire</span><span class="dial-code">+225</span>
</li>
<li class="country" data-dial-code="385" data-country-code="hr">
<div class="flag-box">
<div class="iti-flag hr"></div>
</div><span class="country-name">Croatia (Hrvatska)</span><span class="dial-code">+385</span>
</li>
<li class="country" data-dial-code="53" data-country-code="cu">
<div class="flag-box">
<div class="iti-flag cu"></div>
</div><span class="country-name">Cuba</span><span class="dial-code">+53</span>
</li>
<li class="country" data-dial-code="599" data-country-code="cw">
<div class="flag-box">
<div class="iti-flag cw"></div>
</div><span class="country-name">Curaçao</span><span class="dial-code">+599</span>
</li>
<li class="country" data-dial-code="357" data-country-code="cy">
<div class="flag-box">
<div class="iti-flag cy"></div>
</div><span class="country-name">Cyprus (Κύπρος)</span><span class="dial-code">+357</span>
</li>
<li class="country" data-dial-code="420" data-country-code="cz">
<div class="flag-box">
<div class="iti-flag cz"></div>
</div><span class="country-name">Czech Republic (Česká republika)</span><span class="dial-code">+420</span>
</li>
<li class="country" data-dial-code="45" data-country-code="dk">
<div class="flag-box">
<div class="iti-flag dk"></div>
</div><span class="country-name">Denmark (Danmark)</span><span class="dial-code">+45</span>
</li>
<li class="country" data-dial-code="253" data-country-code="dj">
<div class="flag-box">
<div class="iti-flag dj"></div>
</div><span class="country-name">Djibouti</span><span class="dial-code">+253</span>
</li>
<li class="country" data-dial-code="1767" data-country-code="dm">
<div class="flag-box">
<div class="iti-flag dm"></div>
</div><span class="country-name">Dominica</span><span class="dial-code">+1767</span>
</li>
<li class="country" data-dial-code="1" data-country-code="do">
<div class="flag-box">
<div class="iti-flag do"></div>
</div><span class="country-name">Dominican Republic (República Dominicana)</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="593" data-country-code="ec">
<div class="flag-box">
<div class="iti-flag ec"></div>
</div><span class="country-name">Ecuador</span><span class="dial-code">+593</span>
</li>
<li class="country" data-dial-code="20" data-country-code="eg">
<div class="flag-box">
<div class="iti-flag eg"></div>
</div><span class="country-name">Egypt (مصر)</span><span class="dial-code">+20</span>
</li>
<li class="country" data-dial-code="503" data-country-code="sv">
<div class="flag-box">
<div class="iti-flag sv"></div>
</div><span class="country-name">El Salvador</span><span class="dial-code">+503</span>
</li>
<li class="country" data-dial-code="240" data-country-code="gq">
<div class="flag-box">
<div class="iti-flag gq"></div>
</div><span class="country-name">Equatorial Guinea (Guinea Ecuatorial)</span><span class="dial-code">+240</span>
</li>
<li class="country" data-dial-code="291" data-country-code="er">
<div class="flag-box">
<div class="iti-flag er"></div>
</div><span class="country-name">Eritrea</span><span class="dial-code">+291</span>
</li>
<li class="country" data-dial-code="372" data-country-code="ee">
<div class="flag-box">
<div class="iti-flag ee"></div>
</div><span class="country-name">Estonia (Eesti)</span><span class="dial-code">+372</span>
</li>
<li class="country" data-dial-code="251" data-country-code="et">
<div class="flag-box">
<div class="iti-flag et"></div>
</div><span class="country-name">Ethiopia</span><span class="dial-code">+251</span>
</li>
<li class="country" data-dial-code="500" data-country-code="fk">
<div class="flag-box">
<div class="iti-flag fk"></div>
</div><span class="country-name">Falkland Islands (Islas Malvinas)</span><span class="dial-code">+500</span>
</li>
<li class="country" data-dial-code="298" data-country-code="fo">
<div class="flag-box">
<div class="iti-flag fo"></div>
</div><span class="country-name">Faroe Islands (Føroyar)</span><span class="dial-code">+298</span>
</li>
<li class="country" data-dial-code="679" data-country-code="fj">
<div class="flag-box">
<div class="iti-flag fj"></div>
</div><span class="country-name">Fiji</span><span class="dial-code">+679</span>
</li>
<li class="country" data-dial-code="358" data-country-code="fi">
<div class="flag-box">
<div class="iti-flag fi"></div>
</div><span class="country-name">Finland (Suomi)</span><span class="dial-code">+358</span>
</li>
<li class="country" data-dial-code="33" data-country-code="fr">
<div class="flag-box">
<div class="iti-flag fr"></div>
</div><span class="country-name">France</span><span class="dial-code">+33</span>
</li>
<li class="country" data-dial-code="594" data-country-code="gf">
<div class="flag-box">
<div class="iti-flag gf"></div>
</div><span class="country-name">French Guiana (Guyane française)</span><span class="dial-code">+594</span>
</li>
<li class="country" data-dial-code="689" data-country-code="pf">
<div class="flag-box">
<div class="iti-flag pf"></div>
</div><span class="country-name">French Polynesia (Polynésie française)</span><span class="dial-code">+689</span>
</li>
<li class="country" data-dial-code="241" data-country-code="ga">
<div class="flag-box">
<div class="iti-flag ga"></div>
</div><span class="country-name">Gabon</span><span class="dial-code">+241</span>
</li>
<li class="country" data-dial-code="220" data-country-code="gm">
<div class="flag-box">
<div class="iti-flag gm"></div>
</div><span class="country-name">Gambia</span><span class="dial-code">+220</span>
</li>
<li class="country" data-dial-code="995" data-country-code="ge">
<div class="flag-box">
<div class="iti-flag ge"></div>
</div><span class="country-name">Georgia (საქართველო)</span><span class="dial-code">+995</span>
</li>
<li class="country" data-dial-code="49" data-country-code="de">
<div class="flag-box">
<div class="iti-flag de"></div>
</div><span class="country-name">Germany (Deutschland)</span><span class="dial-code">+49</span>
</li>
<li class="country" data-dial-code="233" data-country-code="gh">
<div class="flag-box">
<div class="iti-flag gh"></div>
</div><span class="country-name">Ghana (Gaana)</span><span class="dial-code">+233</span>
</li>
<li class="country" data-dial-code="350" data-country-code="gi">
<div class="flag-box">
<div class="iti-flag gi"></div>
</div><span class="country-name">Gibraltar</span><span class="dial-code">+350</span>
</li>
<li class="country" data-dial-code="30" data-country-code="gr">
<div class="flag-box">
<div class="iti-flag gr"></div>
</div><span class="country-name">Greece (Ελλάδα)</span><span class="dial-code">+30</span>
</li>
<li class="country" data-dial-code="299" data-country-code="gl">
<div class="flag-box">
<div class="iti-flag gl"></div>
</div><span class="country-name">Greenland (Kalaallit Nunaat)</span><span class="dial-code">+299</span>
</li>
<li class="country" data-dial-code="1473" data-country-code="gd">
<div class="flag-box">
<div class="iti-flag gd"></div>
</div><span class="country-name">Grenada</span><span class="dial-code">+1473</span>
</li>
<li class="country" data-dial-code="590" data-country-code="gp">
<div class="flag-box">
<div class="iti-flag gp"></div>
</div><span class="country-name">Guadeloupe</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="1671" data-country-code="gu">
<div class="flag-box">
<div class="iti-flag gu"></div>
</div><span class="country-name">Guam</span><span class="dial-code">+1671</span>
</li>
<li class="country" data-dial-code="502" data-country-code="gt">
<div class="flag-box">
<div class="iti-flag gt"></div>
</div><span class="country-name">Guatemala</span><span class="dial-code">+502</span>
</li>
<li class="country" data-dial-code="44" data-country-code="gg">
<div class="flag-box">
<div class="iti-flag gg"></div>
</div><span class="country-name">Guernsey</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="224" data-country-code="gn">
<div class="flag-box">
<div class="iti-flag gn"></div>
</div><span class="country-name">Guinea (Guinée)</span><span class="dial-code">+224</span>
</li>
<li class="country" data-dial-code="245" data-country-code="gw">
<div class="flag-box">
<div class="iti-flag gw"></div>
</div><span class="country-name">Guinea-Bissau (Guiné Bissau)</span><span class="dial-code">+245</span>
</li>
<li class="country" data-dial-code="592" data-country-code="gy">
<div class="flag-box">
<div class="iti-flag gy"></div>
</div><span class="country-name">Guyana</span><span class="dial-code">+592</span>
</li>
<li class="country" data-dial-code="509" data-country-code="ht">
<div class="flag-box">
<div class="iti-flag ht"></div>
</div><span class="country-name">Haiti</span><span class="dial-code">+509</span>
</li>
<li class="country" data-dial-code="504" data-country-code="hn">
<div class="flag-box">
<div class="iti-flag hn"></div>
</div><span class="country-name">Honduras</span><span class="dial-code">+504</span>
</li>
<li class="country" data-dial-code="852" data-country-code="hk">
<div class="flag-box">
<div class="iti-flag hk"></div>
</div><span class="country-name">Hong Kong (香港)</span><span class="dial-code">+852</span>
</li>
<li class="country" data-dial-code="36" data-country-code="hu">
<div class="flag-box">
<div class="iti-flag hu"></div>
</div><span class="country-name">Hungary (Magyarország)</span><span class="dial-code">+36</span>
</li>
<li class="country" data-dial-code="354" data-country-code="is">
<div class="flag-box">
<div class="iti-flag is"></div>
</div><span class="country-name">Iceland (Ísland)</span><span class="dial-code">+354</span>
</li>
<li class="country" data-dial-code="91" data-country-code="in">
<div class="flag-box">
<div class="iti-flag in"></div>
</div><span class="country-name">India (भारत)</span><span class="dial-code">+91</span>
</li>
<li class="country" data-dial-code="62" data-country-code="id">
<div class="flag-box">
<div class="iti-flag id"></div>
</div><span class="country-name">Indonesia</span><span class="dial-code">+62</span>
</li>
<li class="country" data-dial-code="98" data-country-code="ir">
<div class="flag-box">
<div class="iti-flag ir"></div>
</div><span class="country-name">Iran (ایران)</span><span class="dial-code">+98</span>
</li>
<li class="country" data-dial-code="964" data-country-code="iq">
<div class="flag-box">
<div class="iti-flag iq"></div>
</div><span class="country-name">Iraq (العراق)</span><span class="dial-code">+964</span>
</li>
<li class="country" data-dial-code="353" data-country-code="ie">
<div class="flag-box">
<div class="iti-flag ie"></div>
</div><span class="country-name">Ireland</span><span class="dial-code">+353</span>
</li>
<li class="country" data-dial-code="44" data-country-code="im">
<div class="flag-box">
<div class="iti-flag im"></div>
</div><span class="country-name">Isle of Man</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="972" data-country-code="il">
<div class="flag-box">
<div class="iti-flag il"></div>
</div><span class="country-name">Israel (ישראל)</span><span class="dial-code">+972</span>
</li>
<li class="country" data-dial-code="39" data-country-code="it">
<div class="flag-box">
<div class="iti-flag it"></div>
</div><span class="country-name">Italy (Italia)</span><span class="dial-code">+39</span>
</li>
<li class="country" data-dial-code="1876" data-country-code="jm">
<div class="flag-box">
<div class="iti-flag jm"></div>
</div><span class="country-name">Jamaica</span><span class="dial-code">+1876</span>
</li>
<li class="country" data-dial-code="81" data-country-code="jp">
<div class="flag-box">
<div class="iti-flag jp"></div>
</div><span class="country-name">Japan (日本)</span><span class="dial-code">+81</span>
</li>
<li class="country" data-dial-code="44" data-country-code="je">
<div class="flag-box">
<div class="iti-flag je"></div>
</div><span class="country-name">Jersey</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="962" data-country-code="jo">
<div class="flag-box">
<div class="iti-flag jo"></div>
</div><span class="country-name">Jordan (الأردن)</span><span class="dial-code">+962</span>
</li>
<li class="country" data-dial-code="7" data-country-code="kz">
<div class="flag-box">
<div class="iti-flag kz"></div>
</div><span class="country-name">Kazakhstan (Казахстан)</span><span class="dial-code">+7</span>
</li>
<li class="country" data-dial-code="254" data-country-code="ke">
<div class="flag-box">
<div class="iti-flag ke"></div>
</div><span class="country-name">Kenya</span><span class="dial-code">+254</span>
</li>
<li class="country" data-dial-code="686" data-country-code="ki">
<div class="flag-box">
<div class="iti-flag ki"></div>
</div><span class="country-name">Kiribati</span><span class="dial-code">+686</span>
</li>
<li class="country" data-dial-code="383" data-country-code="xk">
<div class="flag-box">
<div class="iti-flag xk"></div>
</div><span class="country-name">Kosovo</span><span class="dial-code">+383</span>
</li>
<li class="country" data-dial-code="965" data-country-code="kw">
<div class="flag-box">
<div class="iti-flag kw"></div>
</div><span class="country-name">Kuwait (الكويت)</span><span class="dial-code">+965</span>
</li>
<li class="country" data-dial-code="996" data-country-code="kg">
<div class="flag-box">
<div class="iti-flag kg"></div>
</div><span class="country-name">Kyrgyzstan (Кыргызстан)</span><span class="dial-code">+996</span>
</li>
<li class="country" data-dial-code="856" data-country-code="la">
<div class="flag-box">
<div class="iti-flag la"></div>
</div><span class="country-name">Laos (ລາວ)</span><span class="dial-code">+856</span>
</li>
<li class="country" data-dial-code="371" data-country-code="lv">
<div class="flag-box">
<div class="iti-flag lv"></div>
</div><span class="country-name">Latvia (Latvija)</span><span class="dial-code">+371</span>
</li>
<li class="country" data-dial-code="961" data-country-code="lb">
<div class="flag-box">
<div class="iti-flag lb"></div>
</div><span class="country-name">Lebanon (لبنان)</span><span class="dial-code">+961</span>
</li>
<li class="country" data-dial-code="266" data-country-code="ls">
<div class="flag-box">
<div class="iti-flag ls"></div>
</div><span class="country-name">Lesotho</span><span class="dial-code">+266</span>
</li>
<li class="country" data-dial-code="231" data-country-code="lr">
<div class="flag-box">
<div class="iti-flag lr"></div>
</div><span class="country-name">Liberia</span><span class="dial-code">+231</span>
</li>
<li class="country" data-dial-code="218" data-country-code="ly">
<div class="flag-box">
<div class="iti-flag ly"></div>
</div><span class="country-name">Libya (ليبيا)</span><span class="dial-code">+218</span>
</li>
<li class="country" data-dial-code="423" data-country-code="li">
<div class="flag-box">
<div class="iti-flag li"></div>
</div><span class="country-name">Liechtenstein</span><span class="dial-code">+423</span>
</li>
<li class="country" data-dial-code="370" data-country-code="lt">
<div class="flag-box">
<div class="iti-flag lt"></div>
</div><span class="country-name">Lithuania (Lietuva)</span><span class="dial-code">+370</span>
</li>
<li class="country" data-dial-code="352" data-country-code="lu">
<div class="flag-box">
<div class="iti-flag lu"></div>
</div><span class="country-name">Luxembourg</span><span class="dial-code">+352</span>
</li>
<li class="country" data-dial-code="853" data-country-code="mo">
<div class="flag-box">
<div class="iti-flag mo"></div>
</div><span class="country-name">Macau (澳門)</span><span class="dial-code">+853</span>
</li>
<li class="country" data-dial-code="389" data-country-code="mk">
<div class="flag-box">
<div class="iti-flag mk"></div>
</div><span class="country-name">Macedonia (FYROM) (Македонија)</span><span class="dial-code">+389</span>
</li>
<li class="country" data-dial-code="261" data-country-code="mg">
<div class="flag-box">
<div class="iti-flag mg"></div>
</div><span class="country-name">Madagascar (Madagasikara)</span><span class="dial-code">+261</span>
</li>
<li class="country" data-dial-code="265" data-country-code="mw">
<div class="flag-box">
<div class="iti-flag mw"></div>
</div><span class="country-name">Malawi</span><span class="dial-code">+265</span>
</li>
<li class="country" data-dial-code="60" data-country-code="my">
<div class="flag-box">
<div class="iti-flag my"></div>
</div><span class="country-name">Malaysia</span><span class="dial-code">+60</span>
</li>
<li class="country" data-dial-code="960" data-country-code="mv">
<div class="flag-box">
<div class="iti-flag mv"></div>
</div><span class="country-name">Maldives</span><span class="dial-code">+960</span>
</li>
<li class="country" data-dial-code="223" data-country-code="ml">
<div class="flag-box">
<div class="iti-flag ml"></div>
</div><span class="country-name">Mali</span><span class="dial-code">+223</span>
</li>
<li class="country" data-dial-code="356" data-country-code="mt">
<div class="flag-box">
<div class="iti-flag mt"></div>
</div><span class="country-name">Malta</span><span class="dial-code">+356</span>
</li>
<li class="country" data-dial-code="692" data-country-code="mh">
<div class="flag-box">
<div class="iti-flag mh"></div>
</div><span class="country-name">Marshall Islands</span><span class="dial-code">+692</span>
</li>
<li class="country" data-dial-code="596" data-country-code="mq">
<div class="flag-box">
<div class="iti-flag mq"></div>
</div><span class="country-name">Martinique</span><span class="dial-code">+596</span>
</li>
<li class="country" data-dial-code="222" data-country-code="mr">
<div class="flag-box">
<div class="iti-flag mr"></div>
</div><span class="country-name">Mauritania (موريتانيا)</span><span class="dial-code">+222</span>
</li>
<li class="country" data-dial-code="230" data-country-code="mu">
<div class="flag-box">
<div class="iti-flag mu"></div>
</div><span class="country-name">Mauritius (Moris)</span><span class="dial-code">+230</span>
</li>
<li class="country" data-dial-code="262" data-country-code="yt">
<div class="flag-box">
<div class="iti-flag yt"></div>
</div><span class="country-name">Mayotte</span><span class="dial-code">+262</span>
</li>
<li class="country" data-dial-code="52" data-country-code="mx">
<div class="flag-box">
<div class="iti-flag mx"></div>
</div><span class="country-name">Mexico (México)</span><span class="dial-code">+52</span>
</li>
<li class="country" data-dial-code="691" data-country-code="fm">
<div class="flag-box">
<div class="iti-flag fm"></div>
</div><span class="country-name">Micronesia</span><span class="dial-code">+691</span>
</li>
<li class="country" data-dial-code="373" data-country-code="md">
<div class="flag-box">
<div class="iti-flag md"></div>
</div><span class="country-name">Moldova (Republica Moldova)</span><span class="dial-code">+373</span>
</li>
<li class="country" data-dial-code="377" data-country-code="mc">
<div class="flag-box">
<div class="iti-flag mc"></div>
</div><span class="country-name">Monaco</span><span class="dial-code">+377</span>
</li>
<li class="country" data-dial-code="976" data-country-code="mn">
<div class="flag-box">
<div class="iti-flag mn"></div>
</div><span class="country-name">Mongolia (Монгол)</span><span class="dial-code">+976</span>
</li>
<li class="country" data-dial-code="382" data-country-code="me">
<div class="flag-box">
<div class="iti-flag me"></div>
</div><span class="country-name">Montenegro (Crna Gora)</span><span class="dial-code">+382</span>
</li>
<li class="country" data-dial-code="1664" data-country-code="ms">
<div class="flag-box">
<div class="iti-flag ms"></div>
</div><span class="country-name">Montserrat</span><span class="dial-code">+1664</span>
</li>
<li class="country" data-dial-code="212" data-country-code="ma">
<div class="flag-box">
<div class="iti-flag ma"></div>
</div><span class="country-name">Morocco (المغرب)</span><span class="dial-code">+212</span>
</li>
<li class="country" data-dial-code="258" data-country-code="mz">
<div class="flag-box">
<div class="iti-flag mz"></div>
</div><span class="country-name">Mozambique (Moçambique)</span><span class="dial-code">+258</span>
</li>
<li class="country" data-dial-code="95" data-country-code="mm">
<div class="flag-box">
<div class="iti-flag mm"></div>
</div><span class="country-name">Myanmar (Burma) (မြန်မာ)</span><span class="dial-code">+95</span>
</li>
<li class="country" data-dial-code="264" data-country-code="na">
<div class="flag-box">
<div class="iti-flag na"></div>
</div><span class="country-name">Namibia (Namibië)</span><span class="dial-code">+264</span>
</li>
<li class="country" data-dial-code="674" data-country-code="nr">
<div class="flag-box">
<div class="iti-flag nr"></div>
</div><span class="country-name">Nauru</span><span class="dial-code">+674</span>
</li>
<li class="country" data-dial-code="977" data-country-code="np">
<div class="flag-box">
<div class="iti-flag np"></div>
</div><span class="country-name">Nepal (नेपाल)</span><span class="dial-code">+977</span>
</li>
<li class="country" data-dial-code="31" data-country-code="nl">
<div class="flag-box">
<div class="iti-flag nl"></div>
</div><span class="country-name">Netherlands (Nederland)</span><span class="dial-code">+31</span>
</li>
<li class="country" data-dial-code="687" data-country-code="nc">
<div class="flag-box">
<div class="iti-flag nc"></div>
</div><span class="country-name">New Caledonia (Nouvelle-Calédonie)</span><span class="dial-code">+687</span>
</li>
<li class="country" data-dial-code="64" data-country-code="nz">
<div class="flag-box">
<div class="iti-flag nz"></div>
</div><span class="country-name">New Zealand</span><span class="dial-code">+64</span>
</li>
<li class="country" data-dial-code="505" data-country-code="ni">
<div class="flag-box">
<div class="iti-flag ni"></div>
</div><span class="country-name">Nicaragua</span><span class="dial-code">+505</span>
</li>
<li class="country" data-dial-code="227" data-country-code="ne">
<div class="flag-box">
<div class="iti-flag ne"></div>
</div><span class="country-name">Niger (Nijar)</span><span class="dial-code">+227</span>
</li>
<li class="country" data-dial-code="234" data-country-code="ng">
<div class="flag-box">
<div class="iti-flag ng"></div>
</div><span class="country-name">Nigeria</span><span class="dial-code">+234</span>
</li>
<li class="country" data-dial-code="683" data-country-code="nu">
<div class="flag-box">
<div class="iti-flag nu"></div>
</div><span class="country-name">Niue</span><span class="dial-code">+683</span>
</li>
<li class="country" data-dial-code="672" data-country-code="nf">
<div class="flag-box">
<div class="iti-flag nf"></div>
</div><span class="country-name">Norfolk Island</span><span class="dial-code">+672</span>
</li>
<li class="country" data-dial-code="850" data-country-code="kp">
<div class="flag-box">
<div class="iti-flag kp"></div>
</div><span class="country-name">North Korea (조선 민주주의 인민 공화국)</span><span class="dial-code">+850</span>
</li>
<li class="country" data-dial-code="1670" data-country-code="mp">
<div class="flag-box">
<div class="iti-flag mp"></div>
</div><span class="country-name">Northern Mariana Islands</span><span class="dial-code">+1670</span>
</li>
<li class="country" data-dial-code="47" data-country-code="no">
<div class="flag-box">
<div class="iti-flag no"></div>
</div><span class="country-name">Norway (Norge)</span><span class="dial-code">+47</span>
</li>
<li class="country" data-dial-code="968" data-country-code="om">
<div class="flag-box">
<div class="iti-flag om"></div>
</div><span class="country-name">Oman (عُمان)</span><span class="dial-code">+968</span>
</li>
<li class="country" data-dial-code="92" data-country-code="pk">
<div class="flag-box">
<div class="iti-flag pk"></div>
</div><span class="country-name">Pakistan (پاکستان)</span><span class="dial-code">+92</span>
</li>
<li class="country" data-dial-code="680" data-country-code="pw">
<div class="flag-box">
<div class="iti-flag pw"></div>
</div><span class="country-name">Palau</span><span class="dial-code">+680</span>
</li>
<li class="country" data-dial-code="970" data-country-code="ps">
<div class="flag-box">
<div class="iti-flag ps"></div>
</div><span class="country-name">Palestine (فلسطين)</span><span class="dial-code">+970</span>
</li>
<li class="country" data-dial-code="507" data-country-code="pa">
<div class="flag-box">
<div class="iti-flag pa"></div>
</div><span class="country-name">Panama (Panamá)</span><span class="dial-code">+507</span>
</li>
<li class="country" data-dial-code="675" data-country-code="pg">
<div class="flag-box">
<div class="iti-flag pg"></div>
</div><span class="country-name">Papua New Guinea</span><span class="dial-code">+675</span>
</li>
<li class="country" data-dial-code="595" data-country-code="py">
<div class="flag-box">
<div class="iti-flag py"></div>
</div><span class="country-name">Paraguay</span><span class="dial-code">+595</span>
</li>
<li class="country" data-dial-code="51" data-country-code="pe">
<div class="flag-box">
<div class="iti-flag pe"></div>
</div><span class="country-name">Peru (Perú)</span><span class="dial-code">+51</span>
</li>
<li class="country" data-dial-code="63" data-country-code="ph">
<div class="flag-box">
<div class="iti-flag ph"></div>
</div><span class="country-name">Philippines</span><span class="dial-code">+63</span>
</li>
<li class="country" data-dial-code="48" data-country-code="pl">
<div class="flag-box">
<div class="iti-flag pl"></div>
</div><span class="country-name">Poland (Polska)</span><span class="dial-code">+48</span>
</li>
<li class="country" data-dial-code="351" data-country-code="pt">
<div class="flag-box">
<div class="iti-flag pt"></div>
</div><span class="country-name">Portugal</span><span class="dial-code">+351</span>
</li>
<li class="country" data-dial-code="1" data-country-code="pr">
<div class="flag-box">
<div class="iti-flag pr"></div>
</div><span class="country-name">Puerto Rico</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="974" data-country-code="qa">
<div class="flag-box">
<div class="iti-flag qa"></div>
</div><span class="country-name">Qatar (قطر)</span><span class="dial-code">+974</span>
</li>
<li class="country" data-dial-code="262" data-country-code="re">
<div class="flag-box">
<div class="iti-flag re"></div>
</div><span class="country-name">Réunion (La Réunion)</span><span class="dial-code">+262</span>
</li>
<li class="country" data-dial-code="40" data-country-code="ro">
<div class="flag-box">
<div class="iti-flag ro"></div>
</div><span class="country-name">Romania (România)</span><span class="dial-code">+40</span>
</li>
<li class="country" data-dial-code="7" data-country-code="ru">
<div class="flag-box">
<div class="iti-flag ru"></div>
</div><span class="country-name">Russia (Россия)</span><span class="dial-code">+7</span>
</li>
<li class="country" data-dial-code="250" data-country-code="rw">
<div class="flag-box">
<div class="iti-flag rw"></div>
</div><span class="country-name">Rwanda</span><span class="dial-code">+250</span>
</li>
<li class="country" data-dial-code="590" data-country-code="bl">
<div class="flag-box">
<div class="iti-flag bl"></div>
</div><span class="country-name">Saint Barthélemy (Saint-Barthélemy)</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="290" data-country-code="sh">
<div class="flag-box">
<div class="iti-flag sh"></div>
</div><span class="country-name">Saint Helena</span><span class="dial-code">+290</span>
</li>
<li class="country" data-dial-code="1869" data-country-code="kn">
<div class="flag-box">
<div class="iti-flag kn"></div>
</div><span class="country-name">Saint Kitts and Nevis</span><span class="dial-code">+1869</span>
</li>
<li class="country" data-dial-code="1758" data-country-code="lc">
<div class="flag-box">
<div class="iti-flag lc"></div>
</div><span class="country-name">Saint Lucia</span><span class="dial-code">+1758</span>
</li>
<li class="country" data-dial-code="590" data-country-code="mf">
<div class="flag-box">
<div class="iti-flag mf"></div>
</div><span class="country-name">Saint Martin (Saint-Martin (partie française))</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="508" data-country-code="pm">
<div class="flag-box">
<div class="iti-flag pm"></div>
</div><span class="country-name">Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)</span><span class="dial-code">+508</span>
</li>
<li class="country" data-dial-code="1784" data-country-code="vc">
<div class="flag-box">
<div class="iti-flag vc"></div>
</div><span class="country-name">Saint Vincent and the Grenadines</span><span class="dial-code">+1784</span>
</li>
<li class="country" data-dial-code="685" data-country-code="ws">
<div class="flag-box">
<div class="iti-flag ws"></div>
</div><span class="country-name">Samoa</span><span class="dial-code">+685</span>
</li>
<li class="country" data-dial-code="378" data-country-code="sm">
<div class="flag-box">
<div class="iti-flag sm"></div>
</div><span class="country-name">San Marino</span><span class="dial-code">+378</span>
</li>
<li class="country" data-dial-code="239" data-country-code="st">
<div class="flag-box">
<div class="iti-flag st"></div>
</div><span class="country-name">São Tomé and Príncipe (São Tomé e Príncipe)</span><span class="dial-code">+239</span>
</li>
<li class="country" data-dial-code="966" data-country-code="sa">
<div class="flag-box">
<div class="iti-flag sa"></div>
</div><span class="country-name">Saudi Arabia (المملكة العربية السعودية)</span><span class="dial-code">+966</span>
</li>
<li class="country" data-dial-code="221" data-country-code="sn">
<div class="flag-box">
<div class="iti-flag sn"></div>
</div><span class="country-name">Senegal (Sénégal)</span><span class="dial-code">+221</span>
</li>
<li class="country" data-dial-code="381" data-country-code="rs">
<div class="flag-box">
<div class="iti-flag rs"></div>
</div><span class="country-name">Serbia (Србија)</span><span class="dial-code">+381</span>
</li>
<li class="country" data-dial-code="248" data-country-code="sc">
<div class="flag-box">
<div class="iti-flag sc"></div>
</div><span class="country-name">Seychelles</span><span class="dial-code">+248</span>
</li>
<li class="country" data-dial-code="232" data-country-code="sl">
<div class="flag-box">
<div class="iti-flag sl"></div>
</div><span class="country-name">Sierra Leone</span><span class="dial-code">+232</span>
</li>
<li class="country" data-dial-code="65" data-country-code="sg">
<div class="flag-box">
<div class="iti-flag sg"></div>
</div><span class="country-name">Singapore</span><span class="dial-code">+65</span>
</li>
<li class="country" data-dial-code="1721" data-country-code="sx">
<div class="flag-box">
<div class="iti-flag sx"></div>
</div><span class="country-name">Sint Maarten</span><span class="dial-code">+1721</span>
</li>
<li class="country" data-dial-code="421" data-country-code="sk">
<div class="flag-box">
<div class="iti-flag sk"></div>
</div><span class="country-name">Slovakia (Slovensko)</span><span class="dial-code">+421</span>
</li>
<li class="country" data-dial-code="386" data-country-code="si">
<div class="flag-box">
<div class="iti-flag si"></div>
</div><span class="country-name">Slovenia (Slovenija)</span><span class="dial-code">+386</span>
</li>
<li class="country" data-dial-code="677" data-country-code="sb">
<div class="flag-box">
<div class="iti-flag sb"></div>
</div><span class="country-name">Solomon Islands</span><span class="dial-code">+677</span>
</li>
<li class="country" data-dial-code="252" data-country-code="so">
<div class="flag-box">
<div class="iti-flag so"></div>
</div><span class="country-name">Somalia (Soomaaliya)</span><span class="dial-code">+252</span>
</li>
<li class="country" data-dial-code="27" data-country-code="za">
<div class="flag-box">
<div class="iti-flag za"></div>
</div><span class="country-name">South Africa</span><span class="dial-code">+27</span>
</li>
<li class="country" data-dial-code="82" data-country-code="kr">
<div class="flag-box">
<div class="iti-flag kr"></div>
</div><span class="country-name">South Korea (대한민국)</span><span class="dial-code">+82</span>
</li>
<li class="country" data-dial-code="211" data-country-code="ss">
<div class="flag-box">
<div class="iti-flag ss"></div>
</div><span class="country-name">South Sudan (جنوب السودان)</span><span class="dial-code">+211</span>
</li>
<li class="country" data-dial-code="34" data-country-code="es">
<div class="flag-box">
<div class="iti-flag es"></div>
</div><span class="country-name">Spain (España)</span><span class="dial-code">+34</span>
</li>
<li class="country" data-dial-code="94" data-country-code="lk">
<div class="flag-box">
<div class="iti-flag lk"></div>
</div><span class="country-name">Sri Lanka (ශ්රී ලංකාව)</span><span class="dial-code">+94</span>
</li>
<li class="country" data-dial-code="249" data-country-code="sd">
<div class="flag-box">
<div class="iti-flag sd"></div>
</div><span class="country-name">Sudan (السودان)</span><span class="dial-code">+249</span>
</li>
<li class="country" data-dial-code="597" data-country-code="sr">
<div class="flag-box">
<div class="iti-flag sr"></div>
</div><span class="country-name">Suriname</span><span class="dial-code">+597</span>
</li>
<li class="country" data-dial-code="47" data-country-code="sj">
<div class="flag-box">
<div class="iti-flag sj"></div>
</div><span class="country-name">Svalbard and Jan Mayen</span><span class="dial-code">+47</span>
</li>
<li class="country" data-dial-code="268" data-country-code="sz">
<div class="flag-box">
<div class="iti-flag sz"></div>
</div><span class="country-name">Swaziland</span><span class="dial-code">+268</span>
</li>
<li class="country" data-dial-code="46" data-country-code="se">
<div class="flag-box">
<div class="iti-flag se"></div>
</div><span class="country-name">Sweden (Sverige)</span><span class="dial-code">+46</span>
</li>
<li class="country" data-dial-code="41" data-country-code="ch">
<div class="flag-box">
<div class="iti-flag ch"></div>
</div><span class="country-name">Switzerland (Schweiz)</span><span class="dial-code">+41</span>
</li>
<li class="country" data-dial-code="963" data-country-code="sy">
<div class="flag-box">
<div class="iti-flag sy"></div>
</div><span class="country-name">Syria (سوريا)</span><span class="dial-code">+963</span>
</li>
<li class="country" data-dial-code="886" data-country-code="tw">
<div class="flag-box">
<div class="iti-flag tw"></div>
</div><span class="country-name">Taiwan (台灣)</span><span class="dial-code">+886</span>
</li>
<li class="country" data-dial-code="992" data-country-code="tj">
<div class="flag-box">
<div class="iti-flag tj"></div>
</div><span class="country-name">Tajikistan</span><span class="dial-code">+992</span>
</li>
<li class="country" data-dial-code="255" data-country-code="tz">
<div class="flag-box">
<div class="iti-flag tz"></div>
</div><span class="country-name">Tanzania</span><span class="dial-code">+255</span>
</li>
<li class="country" data-dial-code="66" data-country-code="th">
<div class="flag-box">
<div class="iti-flag th"></div>
</div><span class="country-name">Thailand (ไทย)</span><span class="dial-code">+66</span>
</li>
<li class="country" data-dial-code="670" data-country-code="tl">
<div class="flag-box">
<div class="iti-flag tl"></div>
</div><span class="country-name">Timor-Leste</span><span class="dial-code">+670</span>
</li>
<li class="country" data-dial-code="228" data-country-code="tg">
<div class="flag-box">
<div class="iti-flag tg"></div>
</div><span class="country-name">Togo</span><span class="dial-code">+228</span>
</li>
<li class="country" data-dial-code="690" data-country-code="tk">
<div class="flag-box">
<div class="iti-flag tk"></div>
</div><span class="country-name">Tokelau</span><span class="dial-code">+690</span>
</li>
<li class="country" data-dial-code="676" data-country-code="to">
<div class="flag-box">
<div class="iti-flag to"></div>
</div><span class="country-name">Tonga</span><span class="dial-code">+676</span>
</li>
<li class="country" data-dial-code="1868" data-country-code="tt">
<div class="flag-box">
<div class="iti-flag tt"></div>
</div><span class="country-name">Trinidad and Tobago</span><span class="dial-code">+1868</span>
</li>
<li class="country" data-dial-code="216" data-country-code="tn">
<div class="flag-box">
<div class="iti-flag tn"></div>
</div><span class="country-name">Tunisia (تونس)</span><span class="dial-code">+216</span>
</li>
<li class="country" data-dial-code="90" data-country-code="tr">
<div class="flag-box">
<div class="iti-flag tr"></div>
</div><span class="country-name">Turkey (Türkiye)</span><span class="dial-code">+90</span>
</li>
<li class="country" data-dial-code="993" data-country-code="tm">
<div class="flag-box">
<div class="iti-flag tm"></div>
</div><span class="country-name">Turkmenistan</span><span class="dial-code">+993</span>
</li>
<li class="country" data-dial-code="1649" data-country-code="tc">
<div class="flag-box">
<div class="iti-flag tc"></div>
</div><span class="country-name">Turks and Caicos Islands</span><span class="dial-code">+1649</span>
</li>
<li class="country" data-dial-code="688" data-country-code="tv">
<div class="flag-box">
<div class="iti-flag tv"></div>
</div><span class="country-name">Tuvalu</span><span class="dial-code">+688</span>
</li>
<li class="country" data-dial-code="1340" data-country-code="vi">
<div class="flag-box">
<div class="iti-flag vi"></div>
</div><span class="country-name">U.S. Virgin Islands</span><span class="dial-code">+1340</span>
</li>
<li class="country" data-dial-code="256" data-country-code="ug">
<div class="flag-box">
<div class="iti-flag ug"></div>
</div><span class="country-name">Uganda</span><span class="dial-code">+256</span>
</li>
<li class="country" data-dial-code="380" data-country-code="ua">
<div class="flag-box">
<div class="iti-flag ua"></div>
</div><span class="country-name">Ukraine (Україна)</span><span class="dial-code">+380</span>
</li>
<li class="country" data-dial-code="971" data-country-code="ae">
<div class="flag-box">
<div class="iti-flag ae"></div>
</div><span class="country-name">United Arab Emirates (الإمارات العربية المتحدة)</span><span class="dial-code">+971</span>
</li>
<li class="country" data-dial-code="44" data-country-code="gb">
<div class="flag-box">
<div class="iti-flag gb"></div>
</div><span class="country-name">United Kingdom</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="1" data-country-code="us">
<div class="flag-box">
<div class="iti-flag us"></div>
</div><span class="country-name">United States</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="598" data-country-code="uy">
<div class="flag-box">
<div class="iti-flag uy"></div>
</div><span class="country-name">Uruguay</span><span class="dial-code">+598</span>
</li>
<li class="country" data-dial-code="998" data-country-code="uz">
<div class="flag-box">
<div class="iti-flag uz"></div>
</div><span class="country-name">Uzbekistan (Oʻzbekiston)</span><span class="dial-code">+998</span>
</li>
<li class="country" data-dial-code="678" data-country-code="vu">
<div class="flag-box">
<div class="iti-flag vu"></div>
</div><span class="country-name">Vanuatu</span><span class="dial-code">+678</span>
</li>
<li class="country" data-dial-code="39" data-country-code="va">
<div class="flag-box">
<div class="iti-flag va"></div>
</div><span class="country-name">Vatican City (Città del Vaticano)</span><span class="dial-code">+39</span>
</li>
<li class="country" data-dial-code="58" data-country-code="ve">
<div class="flag-box">
<div class="iti-flag ve"></div>
</div><span class="country-name">Venezuela</span><span class="dial-code">+58</span>
</li>
<li class="country" data-dial-code="84" data-country-code="vn">
<div class="flag-box">
<div class="iti-flag vn"></div>
</div><span class="country-name">Vietnam (Việt Nam)</span><span class="dial-code">+84</span>
</li>
<li class="country" data-dial-code="681" data-country-code="wf">
<div class="flag-box">
<div class="iti-flag wf"></div>
</div><span class="country-name">Wallis and Futuna</span><span class="dial-code">+681</span>
</li>
<li class="country" data-dial-code="212" data-country-code="eh">
<div class="flag-box">
<div class="iti-flag eh"></div>
</div><span class="country-name">Western Sahara (الصحراء الغربية)</span><span class="dial-code">+212</span>
</li>
<li class="country" data-dial-code="967" data-country-code="ye">
<div class="flag-box">
<div class="iti-flag ye"></div>
</div><span class="country-name">Yemen (اليمن)</span><span class="dial-code">+967</span>
</li>
<li class="country" data-dial-code="260" data-country-code="zm">
<div class="flag-box">
<div class="iti-flag zm"></div>
</div><span class="country-name">Zambia</span><span class="dial-code">+260</span>
</li>
<li class="country" data-dial-code="263" data-country-code="zw">
<div class="flag-box">
<div class="iti-flag zw"></div>
</div><span class="country-name">Zimbabwe</span><span class="dial-code">+263</span>
</li>
<li class="country" data-dial-code="358" data-country-code="ax">
<div class="flag-box">
<div class="iti-flag ax"></div>
</div><span class="country-name">Åland Islands</span><span class="dial-code">+358</span>
</li>
</ul>
</div><input type="tel" autocomplete="off" class="form-control" name="" id="" placeholder="" value="07853522826">
</div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="refereeemail" class="">Email</label><input name="refereeemail" required="" id="refereeemail" type="email" class="is-untouched is-pristine av-valid form-control" value="kAaronEfe@anglianwater.co.uk"></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="refereejobtitle" class="">Job Title</label><input name="refereejobtitle" required="" id="refereejobtitle" type="text" class="is-untouched is-pristine av-invalid form-control" value=""></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="refereecompany" class="">Company</label><input name="refereecompany" required="" id="refereecompany" type="text" class="is-untouched is-pristine av-invalid form-control" value=""></div>
</div>
<div class="col-12 col-md-12">
<div class="form-group"><label for="refereecapacity" class="">In what capacity did you know the applicant?:</label><textarea name="refereecapacity" required="" id="refereecapacity"
class="is-untouched is-pristine av-invalid form-control"></textarea></div>
</div>
</div>
</div>
</div>
<div class="section-divder">
<div class="card-header">
<h4 class="card-title mb-0">Applicant Details</h4>
</div>
<div class="card-body">
<div class="row">
<div class="position-relative col-12 col-md-6">
<fieldset name="charref" value="No" class="form-group">
<legend>Is it Character Reference ?</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-valid">
<div class="form-check form-check-inline"><input name="charref" label="Yes" id="radio-charref-Yes" type="radio" class="is-untouched is-pristine av-valid form-check-input" value="Yes"><label for="radio-charref-Yes"
class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="charref" label="No" id="radio-charref-No" type="radio" class="is-untouched is-pristine av-valid form-check-input" value="No" checked=""><label for="radio-charref-No"
class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
</div>
<div class="row">
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="applicantfirstname" class="">First name</label><input name="applicantfirstname" required="" id="applicantfirstname" type="text" class="is-untouched is-pristine av-valid form-control"
value="Celestina tobi-eshiema "></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="applicantlastname" class="">Last name</label><input name="applicantlastname" required="" id="applicantlastname" type="text" class="is-untouched is-pristine av-valid form-control" value="Odion "></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="applicantjobtitle" class="">Job Title</label><input name="applicantjobtitle" required="" id="applicantjobtitle" type="text" class="is-untouched is-pristine av-invalid form-control" value=""></div>
</div>
<div class="position-relative col-12 col-md-6">
<div class="form-group"><label for="applicantcompany" class="">Company</label><input name="applicantcompany" required="" id="applicantcompany" type="text" class="is-untouched is-pristine av-invalid form-control" value=""></div>
</div>
<div class="position-relative dates-value col-12 col-md-6">
<div class="form-group"><label>Date Employed from:</label>
<div class="rdt form-control digits"><input type="text" class="form-control" placeholder="Pick Date" value="">
<div class="rdtPicker">
<div class="rdtDays">
<table>
<thead>
<tr>
<th class="rdtPrev"><span>‹</span></th>
<th class="rdtSwitch" colspan="5" data-value="6">July 2023</th>
<th class="rdtNext"><span>›</span></th>
</tr>
<tr>
<th class="dow">Su</th>
<th class="dow">Mo</th>
<th class="dow">Tu</th>
<th class="dow">We</th>
<th class="dow">Th</th>
<th class="dow">Fr</th>
<th class="dow">Sa</th>
</tr>
</thead>
<tbody>
<tr>
<td data-value="25" class="rdtDay rdtOld">25</td>
<td data-value="26" class="rdtDay rdtOld">26</td>
<td data-value="27" class="rdtDay rdtOld">27</td>
<td data-value="28" class="rdtDay rdtOld">28</td>
<td data-value="29" class="rdtDay rdtOld">29</td>
<td data-value="30" class="rdtDay rdtOld">30</td>
<td data-value="1" class="rdtDay">1</td>
</tr>
<tr>
<td data-value="2" class="rdtDay">2</td>
<td data-value="3" class="rdtDay">3</td>
<td data-value="4" class="rdtDay">4</td>
<td data-value="5" class="rdtDay rdtToday">5</td>
<td data-value="6" class="rdtDay">6</td>
<td data-value="7" class="rdtDay">7</td>
<td data-value="8" class="rdtDay">8</td>
</tr>
<tr>
<td data-value="9" class="rdtDay">9</td>
<td data-value="10" class="rdtDay">10</td>
<td data-value="11" class="rdtDay">11</td>
<td data-value="12" class="rdtDay">12</td>
<td data-value="13" class="rdtDay">13</td>
<td data-value="14" class="rdtDay">14</td>
<td data-value="15" class="rdtDay">15</td>
</tr>
<tr>
<td data-value="16" class="rdtDay">16</td>
<td data-value="17" class="rdtDay">17</td>
<td data-value="18" class="rdtDay">18</td>
<td data-value="19" class="rdtDay">19</td>
<td data-value="20" class="rdtDay">20</td>
<td data-value="21" class="rdtDay">21</td>
<td data-value="22" class="rdtDay">22</td>
</tr>
<tr>
<td data-value="23" class="rdtDay">23</td>
<td data-value="24" class="rdtDay">24</td>
<td data-value="25" class="rdtDay">25</td>
<td data-value="26" class="rdtDay">26</td>
<td data-value="27" class="rdtDay">27</td>
<td data-value="28" class="rdtDay">28</td>
<td data-value="29" class="rdtDay">29</td>
</tr>
<tr>
<td data-value="30" class="rdtDay">30</td>
<td data-value="31" class="rdtDay">31</td>
<td data-value="1" class="rdtDay rdtNew">1</td>
<td data-value="2" class="rdtDay rdtNew">2</td>
<td data-value="3" class="rdtDay rdtNew">3</td>
<td data-value="4" class="rdtDay rdtNew">4</td>
<td data-value="5" class="rdtDay rdtNew">5</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div>
<div class="position-relative dates-value col-12 col-md-6">
<div class="form-group"><label>Date Employed to:</label>
<div class="rdt form-control digits"><input type="text" class="form-control" placeholder="Pick Date" value="">
<div class="rdtPicker">
<div class="rdtDays">
<table>
<thead>
<tr>
<th class="rdtPrev"><span>‹</span></th>
<th class="rdtSwitch" colspan="5" data-value="6">July 2023</th>
<th class="rdtNext"><span>›</span></th>
</tr>
<tr>
<th class="dow">Su</th>
<th class="dow">Mo</th>
<th class="dow">Tu</th>
<th class="dow">We</th>
<th class="dow">Th</th>
<th class="dow">Fr</th>
<th class="dow">Sa</th>
</tr>
</thead>
<tbody>
<tr>
<td data-value="25" class="rdtDay rdtOld">25</td>
<td data-value="26" class="rdtDay rdtOld">26</td>
<td data-value="27" class="rdtDay rdtOld">27</td>
<td data-value="28" class="rdtDay rdtOld">28</td>
<td data-value="29" class="rdtDay rdtOld">29</td>
<td data-value="30" class="rdtDay rdtOld">30</td>
<td data-value="1" class="rdtDay">1</td>
</tr>
<tr>
<td data-value="2" class="rdtDay">2</td>
<td data-value="3" class="rdtDay">3</td>
<td data-value="4" class="rdtDay">4</td>
<td data-value="5" class="rdtDay rdtToday">5</td>
<td data-value="6" class="rdtDay">6</td>
<td data-value="7" class="rdtDay">7</td>
<td data-value="8" class="rdtDay">8</td>
</tr>
<tr>
<td data-value="9" class="rdtDay">9</td>
<td data-value="10" class="rdtDay">10</td>
<td data-value="11" class="rdtDay">11</td>
<td data-value="12" class="rdtDay">12</td>
<td data-value="13" class="rdtDay">13</td>
<td data-value="14" class="rdtDay">14</td>
<td data-value="15" class="rdtDay">15</td>
</tr>
<tr>
<td data-value="16" class="rdtDay">16</td>
<td data-value="17" class="rdtDay">17</td>
<td data-value="18" class="rdtDay">18</td>
<td data-value="19" class="rdtDay">19</td>
<td data-value="20" class="rdtDay">20</td>
<td data-value="21" class="rdtDay">21</td>
<td data-value="22" class="rdtDay">22</td>
</tr>
<tr>
<td data-value="23" class="rdtDay">23</td>
<td data-value="24" class="rdtDay">24</td>
<td data-value="25" class="rdtDay">25</td>
<td data-value="26" class="rdtDay">26</td>
<td data-value="27" class="rdtDay">27</td>
<td data-value="28" class="rdtDay">28</td>
<td data-value="29" class="rdtDay">29</td>
</tr>
<tr>
<td data-value="30" class="rdtDay">30</td>
<td data-value="31" class="rdtDay">31</td>
<td data-value="1" class="rdtDay rdtNew">1</td>
<td data-value="2" class="rdtDay rdtNew">2</td>
<td data-value="3" class="rdtDay rdtNew">3</td>
<td data-value="4" class="rdtDay rdtNew">4</td>
<td data-value="5" class="rdtDay rdtNew">5</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div>
<div class="position-relative col-12 col-md-6">
<fieldset name="remployee" class="form-group">
<legend>Would you re-employ this person?</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="remployee" label="Yes" id="radio-remployee-yes" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="yes"><label for="radio-remployee-yes"
class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="remployee" label="No" id="radio-remployee-no" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="no"><label for="radio-remployee-no"
class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
</div>
</div>
</div>
<div class="section-divder">
<div class="card-header">
<h4 class="card-title mb-0">SECTION 1 - HOW WOULD YOU ASSESS THE FOLLOWING?<small class="card-title-sub">Please tick the relevant boxes Excellent, Good, Average, Poor</small></h4>
</div>
<div class="card-body">
<div class="row">
<div class="position-relative col-12 col-md-4">
<fieldset name="reliability" class="form-group">
<legend>Reliability, timekeeping,attendance</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="reliability" label="Excellent" id="radio-reliability-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-reliability-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="reliability" label="Good" id="radio-reliability-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-reliability-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="reliability" label="Average" id="radio-reliability-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-reliability-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="reliability" label="Poor" id="radio-reliability-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-reliability-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="reliability" label="Not Applicable" id="radio-reliability-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-reliability-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="character" class="form-group">
<legend>Character</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="character" label="Excellent" id="radio-character-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-character-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="character" label="Good" id="radio-character-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-character-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="character" label="Average" id="radio-character-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-character-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="character" label="Poor" id="radio-character-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-character-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="character" label="Not Applicable" id="radio-character-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-character-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="attitude" class="form-group">
<legend>Attitude</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="attitude" label="Excellent" id="radio-attitude-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-attitude-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="attitude" label="Good" id="radio-attitude-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label for="radio-attitude-good"
class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="attitude" label="Average" id="radio-attitude-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-attitude-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="attitude" label="Poor" id="radio-attitude-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label for="radio-attitude-poor"
class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="attitude" label="Not Applicable" id="radio-attitude-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-attitude-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="dignity" class="form-group">
<legend>Ability to ensure dignity is upheld</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="dignity" label="Excellent" id="radio-dignity-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-dignity-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="dignity" label="Good" id="radio-dignity-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label for="radio-dignity-good"
class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="dignity" label="Average" id="radio-dignity-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-dignity-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="dignity" label="Poor" id="radio-dignity-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label for="radio-dignity-poor"
class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="dignity" label="Not Applicable" id="radio-dignity-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="Not Applicable"><label
for="radio-dignity-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="communication" class="form-group">
<legend>Communication</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="communication" label="Excellent" id="radio-communication-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-communication-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="communication" label="Good" id="radio-communication-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-communication-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="communication" label="Average" id="radio-communication-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-communication-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="communication" label="Poor" id="radio-communication-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-communication-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="communication" label="Not Applicable" id="radio-communication-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-communication-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="relationships" class="form-group">
<legend>Relationships with colleagues</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="relationships" label="Excellent" id="radio-relationships-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="excellent"><label
for="radio-relationships-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="relationships" label="Good" id="radio-relationships-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-relationships-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="relationships" label="Average" id="radio-relationships-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-relationships-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="relationships" label="Poor" id="radio-relationships-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-relationships-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="relationships" label="Not Applicable" id="radio-relationships-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-relationships-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="workunderinitiative" class="form-group">
<legend>Ability to work under own initiative</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="workunderinitiative" label="Excellent" id="radio-workunderinitiative-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="excellent"><label for="radio-workunderinitiative-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="workunderinitiative" label="Good" id="radio-workunderinitiative-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-workunderinitiative-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="workunderinitiative" label="Average" id="radio-workunderinitiative-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="average"><label for="radio-workunderinitiative-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="workunderinitiative" label="Poor" id="radio-workunderinitiative-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-workunderinitiative-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="workunderinitiative" label="Not Applicable" id="radio-workunderinitiative-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-workunderinitiative-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-4">
<fieldset name="followcareplans" class="form-group">
<legend>Ability to follow care plans</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="followcareplans" label="Excellent" id="radio-followcareplans-excellent" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="excellent"><label for="radio-followcareplans-excellent" class="form-check-label">Excellent</label></div>
<div class="form-check form-check-inline"><input name="followcareplans" label="Good" id="radio-followcareplans-good" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="good"><label
for="radio-followcareplans-good" class="form-check-label">Good</label></div>
<div class="form-check form-check-inline"><input name="followcareplans" label="Average" id="radio-followcareplans-average" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="average"><label
for="radio-followcareplans-average" class="form-check-label">Average</label></div>
<div class="form-check form-check-inline"><input name="followcareplans" label="Poor" id="radio-followcareplans-poor" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="poor"><label
for="radio-followcareplans-poor" class="form-check-label">Poor</label></div>
<div class="form-check form-check-inline"><input name="followcareplans" label="Not Applicable" id="radio-followcareplans-Not Applicable" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input"
value="Not Applicable"><label for="radio-followcareplans-Not Applicable" class="form-check-label">Not Applicable</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
</div>
</div>
<div class="card-header">
<h4 class="card-title mb-0">SECTION - 2 Please answer the following questions</h4>
</div>
<div class="card-body">
<div class="row">
<div class="position-relative col-12 col-md-6">
<fieldset name="disciplinaryaction" class="form-group">
<legend>Has the applicant been subject to any disciplinary action?</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="disciplinaryaction" label="Yes" id="radio-disciplinaryaction-yes" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="yes"><label
for="radio-disciplinaryaction-yes" class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="disciplinaryaction" label="No" id="radio-disciplinaryaction-no" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="no"><label
for="radio-disciplinaryaction-no" class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-6">
<fieldset name="investigations" class="form-group">
<legend>Are you aware of the applicants involvement in any safeguarding investigations previous or current .</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="investigations" label="Yes" id="radio-investigations-yes" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="yes"><label
for="radio-investigations-yes" class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="investigations" label="No" id="radio-investigations-no" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="no"><label
for="radio-investigations-no" class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-6">
<fieldset name="vulnerablepeople" class="form-group">
<legend>Are you aware of any reasons why the applicant should not be employed to work with children or vulnerable people?</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="vulnerablepeople" label="Yes" id="radio-vulnerablepeople-yes" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="yes"><label
for="radio-vulnerablepeople-yes" class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="vulnerablepeople" label="No" id="radio-vulnerablepeople-no" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="no"><label
for="radio-vulnerablepeople-no" class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-6">
<fieldset name="criminaloffence" class="form-group">
<legend>To the best of your knowledge, has the applicant been convicted or cautioned of a criminal offence?</legend>
<div class="form-control border-0 p-0 h-auto is-untouched is-pristine av-invalid">
<div class="form-check form-check-inline"><input name="criminaloffence" label="Yes" id="radio-criminaloffence-yes" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="yes"><label
for="radio-criminaloffence-yes" class="form-check-label">Yes</label></div>
<div class="form-check form-check-inline"><input name="criminaloffence" label="No" id="radio-criminaloffence-no" required="" type="radio" class="is-untouched is-pristine av-invalid form-check-input" value="no"><label
for="radio-criminaloffence-no" class="form-check-label">No</label></div>
</div>
<div class="valid-feedback"></div>
</fieldset>
</div>
<div class="position-relative col-12 col-md-12">
<div class="form-group"><label for="additionalcomments" class="">Additional Comments</label><textarea name="additionalcomments" placeholder="" id="additionalcomments" class="is-untouched is-pristine av-valid form-control"></textarea></div>
</div>
</div>
</div>
</div>
<div class="card-header">
<div class="confirm-box">
<h4 class="card-title mb-0">PLEASE CONFIRM:</h4>
<p>I can confirm that all the details provided are accurate at the time that this reference was completed. I can confirm that I am authorised to provide a reference on behalf of my organisation. I understand this reference may be shown to a
third party for auditing purposes and I can confirm that Mid-View Healthcare has this organisation's consent and authorisation to disclose the contents of this reference to its end user, hirer clients. I understand that the applicant has the
legal right to request a copy of their reference.</p>
</div>
</div>
<div class="card-body"><label class="checkbox-btn ref-plc">
<div class="form-group"><label for="confirm" class="form-check-label"></label><input name="confirm" required="" id="confirm" type="checkbox" class=" checkbox-btn__checkbox is-untouched is-pristine av-invalid form-check-input"
value="false"><span class="checkbox-btn__checkbox-custom mt-3"><i class="mdi mdi-check"></i></span><span class="checkbox-btn__label">Check to confirm</span>
<div class="valid-feedback">This is required!</div>
</div>
</label>
<div class="card-footer">
<div class="row">
<div class="position-relative col-12 col-md-12"><button class="btn btn-primary">Add Signature</button> <br><br></div>
</div>
</div>
<div class="position-relative offical-box col-12 col-md-12"><label for="exampleCustomFileBrowser" class="offical-box-text">Official company stamp.</label>
<div class="custom-file"><input type="file" id="exampleCustomFileBrowser" name="campanystamp" enctype="multipart/form-data" accept=".png, .jpg, .jpeg" class="custom-file-input"><label class="custom-file-label"
for="exampleCustomFileBrowser">Upload Image</label></div>
</div>
<div class="mid-values">
<p>If you are not using an official company email please upload a picture of your company stamp / business card/letterhead/compliment slip.</p>
</div><label class="checkbox-btn">
<div class="form-group"><label for="agree" class="form-check-label"></label><input name="agree" required="" id="agree" type="checkbox" class="checkbox-btn__checkbox is-untouched is-pristine av-invalid form-check-input" value="false"><span
class="checkbox-btn__checkbox-custom mt-3"><i class="mdi mdi-check"></i></span><span class="checkbox-btn__label">By using this form you agree with the storage and handling of your data by this website as defined in our Privacy
Policy.</span>
<div class="valid-feedback">This is required!</div>
</div>
</label>
</div>
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You need to enable JavaScript to run this app. REFERENCE FORM PLEASE COMPLETE THE REFERENCE FORM AND SUBMIT REFEREE DETAILS First name Last name Phone * United States+1 * United Kingdom+44 * Afghanistan (افغانستان)+93 * Albania (Shqipëri)+355 * Algeria (الجزائر)+213 * American Samoa+1684 * Andorra+376 * Angola+244 * Anguilla+1264 * Antigua and Barbuda+1268 * Argentina+54 * Armenia (Հայաստան)+374 * Aruba+297 * Australia+61 * Austria (Österreich)+43 * Azerbaijan (Azərbaycan)+994 * Bahamas+1242 * Bahrain (البحرين)+973 * Bangladesh (বাংলাদেশ)+880 * Barbados+1246 * Belarus (Беларусь)+375 * Belgium (België)+32 * Belize+501 * Benin (Bénin)+229 * Bermuda+1441 * Bhutan (འབྲུག)+975 * Bolivia+591 * Bosnia and Herzegovina (Босна и Херцеговина)+387 * Botswana+267 * Brazil (Brasil)+55 * British Indian Ocean Territory+246 * British Virgin Islands+1284 * Brunei+673 * Bulgaria (България)+359 * Burkina Faso+226 * Burundi (Uburundi)+257 * Cambodia (កម្ពុជា)+855 * Cameroon (Cameroun)+237 * Canada+1 * Cape Verde (Kabu Verdi)+238 * Caribbean Netherlands+599 * Cayman Islands+1345 * Central African Republic (République centrafricaine)+236 * Chad (Tchad)+235 * Chile+56 * China (中国)+86 * Christmas Island+61 * Cocos (Keeling) Islands+61 * Colombia+57 * Comoros (جزر القمر)+269 * Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243 * Congo (Republic) (Congo-Brazzaville)+242 * Cook Islands+682 * Costa Rica+506 * Côte d’Ivoire+225 * Croatia (Hrvatska)+385 * Cuba+53 * Curaçao+599 * Cyprus (Κύπρος)+357 * Czech Republic (Česká republika)+420 * Denmark (Danmark)+45 * Djibouti+253 * Dominica+1767 * Dominican Republic (República Dominicana)+1 * Ecuador+593 * Egypt (مصر)+20 * El Salvador+503 * Equatorial Guinea (Guinea Ecuatorial)+240 * Eritrea+291 * Estonia (Eesti)+372 * Ethiopia+251 * Falkland Islands (Islas Malvinas)+500 * Faroe Islands (Føroyar)+298 * Fiji+679 * Finland (Suomi)+358 * France+33 * French Guiana (Guyane française)+594 * French Polynesia (Polynésie française)+689 * Gabon+241 * Gambia+220 * Georgia (საქართველო)+995 * Germany (Deutschland)+49 * Ghana (Gaana)+233 * Gibraltar+350 * Greece (Ελλάδα)+30 * Greenland (Kalaallit Nunaat)+299 * Grenada+1473 * Guadeloupe+590 * Guam+1671 * Guatemala+502 * Guernsey+44 * Guinea (Guinée)+224 * Guinea-Bissau (Guiné Bissau)+245 * Guyana+592 * Haiti+509 * Honduras+504 * Hong Kong (香港)+852 * Hungary (Magyarország)+36 * Iceland (Ísland)+354 * India (भारत)+91 * Indonesia+62 * Iran (ایران)+98 * Iraq (العراق)+964 * Ireland+353 * Isle of Man+44 * Israel (ישראל)+972 * Italy (Italia)+39 * Jamaica+1876 * Japan (日本)+81 * Jersey+44 * Jordan (الأردن)+962 * Kazakhstan (Казахстан)+7 * Kenya+254 * Kiribati+686 * Kosovo+383 * Kuwait (الكويت)+965 * Kyrgyzstan (Кыргызстан)+996 * Laos (ລາວ)+856 * Latvia (Latvija)+371 * Lebanon (لبنان)+961 * Lesotho+266 * Liberia+231 * Libya (ليبيا)+218 * Liechtenstein+423 * Lithuania (Lietuva)+370 * Luxembourg+352 * Macau (澳門)+853 * Macedonia (FYROM) (Македонија)+389 * Madagascar (Madagasikara)+261 * Malawi+265 * Malaysia+60 * Maldives+960 * Mali+223 * Malta+356 * Marshall Islands+692 * Martinique+596 * Mauritania (موريتانيا)+222 * Mauritius (Moris)+230 * Mayotte+262 * Mexico (México)+52 * Micronesia+691 * Moldova (Republica Moldova)+373 * Monaco+377 * Mongolia (Монгол)+976 * Montenegro (Crna Gora)+382 * Montserrat+1664 * Morocco (المغرب)+212 * Mozambique (Moçambique)+258 * Myanmar (Burma) (မြန်မာ)+95 * Namibia (Namibië)+264 * Nauru+674 * Nepal (नेपाल)+977 * Netherlands (Nederland)+31 * New Caledonia (Nouvelle-Calédonie)+687 * New Zealand+64 * Nicaragua+505 * Niger (Nijar)+227 * Nigeria+234 * Niue+683 * Norfolk Island+672 * North Korea (조선 민주주의 인민 공화국)+850 * Northern Mariana Islands+1670 * Norway (Norge)+47 * Oman (عُمان)+968 * Pakistan (پاکستان)+92 * Palau+680 * Palestine (فلسطين)+970 * Panama (Panamá)+507 * Papua New Guinea+675 * Paraguay+595 * Peru (Perú)+51 * Philippines+63 * Poland (Polska)+48 * Portugal+351 * Puerto Rico+1 * Qatar (قطر)+974 * Réunion (La Réunion)+262 * Romania (România)+40 * Russia (Россия)+7 * Rwanda+250 * Saint Barthélemy (Saint-Barthélemy)+590 * Saint Helena+290 * Saint Kitts and Nevis+1869 * Saint Lucia+1758 * Saint Martin (Saint-Martin (partie française))+590 * Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508 * Saint Vincent and the Grenadines+1784 * Samoa+685 * San Marino+378 * São Tomé and Príncipe (São Tomé e Príncipe)+239 * Saudi Arabia (المملكة العربية السعودية)+966 * Senegal (Sénégal)+221 * Serbia (Србија)+381 * Seychelles+248 * Sierra Leone+232 * Singapore+65 * Sint Maarten+1721 * Slovakia (Slovensko)+421 * Slovenia (Slovenija)+386 * Solomon Islands+677 * Somalia (Soomaaliya)+252 * South Africa+27 * South Korea (대한민국)+82 * South Sudan (جنوب السودان)+211 * Spain (España)+34 * Sri Lanka (ශ්රී ලංකාව)+94 * Sudan (السودان)+249 * Suriname+597 * Svalbard and Jan Mayen+47 * Swaziland+268 * Sweden (Sverige)+46 * Switzerland (Schweiz)+41 * Syria (سوريا)+963 * Taiwan (台灣)+886 * Tajikistan+992 * Tanzania+255 * Thailand (ไทย)+66 * Timor-Leste+670 * Togo+228 * Tokelau+690 * Tonga+676 * Trinidad and Tobago+1868 * Tunisia (تونس)+216 * Turkey (Türkiye)+90 * Turkmenistan+993 * Turks and Caicos Islands+1649 * Tuvalu+688 * U.S. Virgin Islands+1340 * Uganda+256 * Ukraine (Україна)+380 * United Arab Emirates (الإمارات العربية المتحدة)+971 * United Kingdom+44 * United States+1 * Uruguay+598 * Uzbekistan (Oʻzbekiston)+998 * Vanuatu+678 * Vatican City (Città del Vaticano)+39 * Venezuela+58 * Vietnam (Việt Nam)+84 * Wallis and Futuna+681 * Western Sahara (الصحراء الغربية)+212 * Yemen (اليمن)+967 * Zambia+260 * Zimbabwe+263 * Åland Islands+358 Email Job Title Company In what capacity did you know the applicant?: APPLICANT DETAILS Is it Character Reference ? Yes No First name Last name Job Title Company Date Employed from: ‹July 2023›SuMoTuWeThFrSa2526272829301234567891011121314151617181920212223242526272829303112345 Date Employed to: ‹July 2023›SuMoTuWeThFrSa2526272829301234567891011121314151617181920212223242526272829303112345 Would you re-employ this person? Yes No SECTION 1 - HOW WOULD YOU ASSESS THE FOLLOWING?PLEASE TICK THE RELEVANT BOXES EXCELLENT, GOOD, AVERAGE, POOR Reliability, timekeeping,attendance Excellent Good Average Poor Not Applicable Character Excellent Good Average Poor Not Applicable Attitude Excellent Good Average Poor Not Applicable Ability to ensure dignity is upheld Excellent Good Average Poor Not Applicable Communication Excellent Good Average Poor Not Applicable Relationships with colleagues Excellent Good Average Poor Not Applicable Ability to work under own initiative Excellent Good Average Poor Not Applicable Ability to follow care plans Excellent Good Average Poor Not Applicable SECTION - 2 PLEASE ANSWER THE FOLLOWING QUESTIONS Has the applicant been subject to any disciplinary action? Yes No Are you aware of the applicants involvement in any safeguarding investigations previous or current . Yes No Are you aware of any reasons why the applicant should not be employed to work with children or vulnerable people? Yes No To the best of your knowledge, has the applicant been convicted or cautioned of a criminal offence? Yes No Additional Comments PLEASE CONFIRM: I can confirm that all the details provided are accurate at the time that this reference was completed. I can confirm that I am authorised to provide a reference on behalf of my organisation. I understand this reference may be shown to a third party for auditing purposes and I can confirm that Mid-View Healthcare has this organisation's consent and authorisation to disclose the contents of this reference to its end user, hirer clients. I understand that the applicant has the legal right to request a copy of their reference. Check to confirm This is required! Add Signature Official company stamp. Upload Image If you are not using an official company email please upload a picture of your company stamp / business card/letterhead/compliment slip. 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