Referee’s Confidential Report

A prospective student is required to provide three references.

If you were asked to complete a Reference Form, please complete the form below and submit it.

Thank you!


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.