DTS Confidential reference

CONFIDENTIAL REFERENCE

For completion by a friend or a colleague
WHAT IS YOUR NAME?*

First NameMiddle NameLast Name
WHAT IS THE NAME OF WHOM YOU ARE REFERRING ?*

First NameMiddle NameLast Name
SCHOOL STARTING MONTH
The above named applicant has applied for admission to the above-named school at Youth With A Mission Mbabane. In order to adequately evaluate the applicant for admission, we would appreciate your supplying the information requested on this form. Your comments will help us to make a wise decision in accepting the applicant and effectively meeting his/her need should he/she be accepted into the program applied for.
How long have you known the applicant? *
CHURCH

PastorHome group leaderOther
BUSINESS

EmployerSupervisorCo-worker
SCHOOL

PrincipalTeacherOther
SOCIAL

Family friendPersonal friendOther
YWAM

School leaderSmall group leaderOther
On a scale of 1-10, how well do you feel you know the applicant? (1=very little; 10=intimately)*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
For how long has the applicant attended your church or been involved in your program?(if applicable) *
In what ways has the applicant been involved in the church or your program?*
In your association with the applicant, what has been the level of commitment you have seen exemplified?*

FaithfulInconsistentOther
Please describe in your own word how you would rate the applicant in the following areas:
Initiative
Social adaptability
Personal appearance
Concern for others
Leadership
Emotional stability
Ability to follow
Flexibility
Stewardship
Reliability
Cooperation
Self discipline
Christian Character
Temperament
Punctuality
Perseverance
Ability to cope with stress
Please choose words or descriptions, which pertain to the applicant:*

ImpatientIntolerantArgumentativeDomineeringCritical of othersEasily embarrassedOffendedDiscouragedFrequently worriedAnxiousNervous or tenseGiven to moodsPrejudice towards groups/races/nationalitiesAddictive behaviorErratic in attitudes and actions
(If you have noticed any of these or similar limitations in the applicant's life, please elaborate here)
Has the applicant proven on any occasion to be unreliable, dishonest or of questionable character?*

YESNO
If YES, please explain.
In your consideration, which of the following would best describe the applicant's Christian experience?*

MatureContagiousGenuine and growingOver emotionalSuperficial
Please comment briefly on the applicant's family background (if known):
Does the applicant display prejudice towards other races or nationalities?*

YESNOUNAWARE
Comments:
Has the applicant ever been involved in the occult, drug or alcohol abuse or sexual immorality?*

YESNOUNAWARE
Does the applicant smoke?*

YESNOUNAWARE
Comments:
Is the applicant financially responsible?*

YESNOUNAWARE
Comments:
Does the applicant respond well to authority?*

YESNOUNAWARE
Would you please make any comments regarding the applicant which you feel could be helpful:
Do you recommend the applicant?*

WholeheartedlyWith reservationNot at all
I declare that the contents of this confidential reference are correct to the best of my knowledge.
PERSONAL INFORMATION
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMAIL*
example@example.com
PHONE*
SIGNATURE*
DATE*

MonthDayYear
Date
Could we contact you if we require any further information?

YESNO
Should be Empty:

CONFIDENTIAL REFERENCE

PERSONAL INFORMATION