Reference Form For Undergraduate Degree Programs


Reference Form for Undergraduate Degree Programs
To be completed by applicant:
Name of applicant: ____________________________________________________ Other name(s) used: __________________________________________
Address: _________________________________________________________________________________________________________________________
City:_____________________________________State:________ Zip:________________ Phone: (_________) _______________________
 Adult Cardiac Sonography & Vascular Sonography – dual major
 Healthcare Studies
Program applying for:
 Biomedical Sciences
 Health Sciences
 Diagnostic Medical Sonography
 Nursing (BSN)
RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to inspect their files upon request. In order to inform the
person you have requested to complete this reference form whether the form will be held in confidence or if the letter will be open to your inspection,
please check one of the following statements. Waiving your rights to see this form is not a requirement for admissions.
 I do hereby waive my right to access this reference form.
 I do not hereby waive my rights to access this form.
Applicant Signature: ___________________________________________ Date: _______________________
Please return by: ________________________
To be completed by reference:
Reference name: _____________________________________________________________________ Date: _______________________________________
(please print)
Relationship to applicant: _________________________________________ How long have you known the applicant: ______________________________
How well do you know the applicant?  Very well
 Somewhat well
 Not well
Below Average
No Basis
for Judgment
1. Ability to work with people
a. Solve problems with others
b. Inspire enthusiasm in others
c. Remain warm & accepting
d. Work on a team
2. Leadership
3. Personal initiative
4. Growth potential
5. Concern for others
6. Motivation
7. Integrity
8. Reliability
9. Reaction to setbacks
If rated below average, please comment:


00 votes

Related Articles

Related forms

Related Categories

Parent category: Letters
Page of 2