Please enter street address including city, state, and zip code.

    Please answer the following questions fully with honesty.

    Do not answer questions if you do not feel knowledgeable. The report will be dealt with in the strictest confidence.

    (a) The opposite sex(b) Family(c) Friends/Church Members(d) Workplace


    Please give your honest opinion of the applicant by marking the block which best describes the applicant.

    Well balancedUsually balancedEasily depressed or excitedUnresponsive
    Seeks additional tasksDoes extra assignmentsNeeds occasional promptingNeeds constant prompting
    Sound decisionsGood conclusionsPoor resultsLacks ability
    Exceptionally reliableVery reliableUsually reliableUnreliable
    Very goodGoodAverageWeak
    Consistently a leaderUsually a leaderSeldom leads othersNever takes the lead

    Further Comments

    Please make further comments regarding the applicant, which may not have been covered in the above sections and which may assist us in our consideration of the applicant.

    I have answered the questions with honesty.