Confidential: Pastor'S Reference Form printable pdf download

Admissions Office

820 N. LaSalle Blvd. • Chicago, Illinois 60610-3284

(800) 967-4624 • apply@moody.edu • moody.edu

Confidential: Pastor’s Reference Form

This portion is to be completed by the applicant:

Name of Applicant ______________________________________________________________________________________________

Name of Pastor ________________________________________ Position _________________________________________________

The purpose for which this confidential reference form is being obtained is admissions to The Moody Bible Institute of Chicago (“Moody Bible Institute”).

It will be received and maintained in confidence. If you are admitted and enrolled, and if Moody Bible Institute retains this confidential reference form, you

may inspect this reference form and any attachments pursuant to The Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99),

unless you have voluntarily waived this right by signing the following statement: WAIVER OF RIGHT TO ACCESS: I, the undersigned, hereby expressly and

voluntarily waive any and all access rights I might have to this confidential reference form under The Family Educational Rights and Privacy Act (20 U.S.C. §

1232g; 34 CFR Part 99), any state law, or any other laws, regulations, or policies. I understand that the observations made shall remain confidential between

the writer and the Moody Bible Institute. I acknowledge and represent that I am over the age of 18, have carefully read and understand this Waiver of Right

to Access, and I have signed it knowingly and voluntarily.

Signature of Applicant __________________________________________________________________ Date _____________________

Parent or Guardian Signature (if under 18) ____________________________________________________ Date _____________________

(The signing of this waiver is voluntary. It is not required as a condition for admission.)

INSTRUCTIONS TO THE REFERENT: Thank you for taking the time to fill out this application. We realize your time is valuable and we appreciate your willingness

to help us. The clearer and more factual you can be enables us to serve the applicant in the best way possible. The person named above is applying for admission

to Moody Bible Institute, a Christian institution whose purpose is to train persons for vocations in full-time ministry. Please be frank, fair, and accurate in your

remarks and estimation. Please note the FERPA provisory as shown above. Although the applicant may voluntarily waive the right to review this reference, it is

hoped that a spirit of openness and candor will exist between the applicant and the referent regarding this reference. After completing this form, please email it to

apply@moody.edu or mail in the envelope provided by the student.

1. How long have you known the applicant? ________ years ________ months

2. Are you acquainted with the applicant’s spiritual life? ______________________________________________________________________

Business life? ____________________________________________ Social life? ____________________________________________

3. Are the parents saved? __________________________________________________________________________________________

Please describe the applicant’s home life.______________________________________________________________________________

4. In what capacities has (s)he been active in your church? ___________________________________________________________________

5. Has (s)he any significant talents or special abilities?

Yes