MOM Scholarship Reference and Rating Form

Mary E Smith (M.O.M) Foundation, Inc./ Memories of Mary

REFERENCE & RATING FORM DEADLINE February 1st
BACKGROUND:

You are recieving this Reference & Rating Form on behalf of a student who has applied to our charity for a scholarship. This scholarship is in support of their academic achievement and community involvement.

As an organization we are committed to winning the fight against brain tumors, the elgible applicant is either pursuing interest in this field of work; or is a patient themselves or family member of a patient affected by this condition. It is our mission to bring the brightest minds into the field and to support the brain tumor community. We THANK YOU for taking the time to assist us in meeting our goal.
REFERRING PERSON INFORMATION
Name of Reference Provider*

First NameLast Name
Reference Provider Email Address*
example@example.com
Reference Provider Contact Phone Number*
Please enter a valid phone number.
Reference Provider Title*
Reference Affiliated Organization/Institution Name*
Organization/Institution Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ABOUT THE APPLICANT:
APPLICANT'S Name*

First NameLast Name
HOW LONG AND IN WHAT CAPACITY YOU KNOW THE APPLICANT:*
APPLICANT'S SCHOOL RANK:
Cumulative G.P.A.
APPLICANT RATING:
PLEASE SELECT ONE RATING IN EACH CATEGORY TO ASSESS THE FOLLOWING QUALITIES OF THE APPLICANT
Capacity for learning*
Attitude towards work (Work Ethic)*
Cooperativeness*
Leadership abilities*
Is dependable and responsible*
LETTER OF RECOMMENDATION:
Please provide supporting commentary below:*
*ONLY If additional character space is needed, you may email to information@maryesmithfoundation.org with student name & the word REFERENCE in the subject line.
Please Check Recommendation Overall Rating*

RecommendStrongly RecommendRecommend with ReservationsDo Not Recommend
REFERRING PERSON ATTESTATION
I am providing my signature to attest that this rating form and recommendation was completed by me and is accurate to the best of my knowledge.*

YES I AGREE
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

Mary E Smith (M.O.M) Foundation, Inc./ Memories of Mary