Admissions Reference Form

Admissions Reference Form

This form is completed by references for applicants to the SoMoTech Practical Nursing and Surgical Technology programs.
Applicant Name*

First NameLast Name
Reference (Your) Name*

First NameLast Name
Reference (Your) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference (Your) Email Address*
example@example.com
Reference (Your) Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How long have you known the applicant?*
(Months/Years)
In what capacity have you known the applicant?*
Personal/Professional/Academic
What sort of relationship did the applicant establish with those around them?
From your experience with the applicant, how would you rate his/her work ethic (attendance, promptness, dependability, etc.)?

1

2

3

4

5

1 is Poor, 5 is Excellent
From your experience with the applicant, how would you rate his/her academic ability and willingness to learn new knowledge and skills?

1

2

3

4

5

1 is Poor, 5 is Excellent
From your experience with the applicant, how would you rate his/her reliability in terms of completing tasks, being self-motivated, and accepting of constructive criticism?

1

2

3

4

5

1 is Poor, 5 is Excellent
From your experience with the applicant, how would you rate his/her ability to communicate effectively and build positive interpersonal relationships?

1

2

3

4

5

1 is Poor, 5 is Excellent
From your experience with the applicant, how would you rate his/her ability to maintain composure, function effectively in stressful situations, and using sound judgment?

1

2

3

4

5

1 is Poor, 5 is Excellent
Would you recommend the applicant for a position which requires responsibility and stability?

YesNo
Please provide us with any additional information that you think may help inform our decision whether or not to admit this applicant.
Finally, how would you describe your recommendation of this applicant?*

Recommend with enthusiasmRecommendDo not recommendUnable to evaluate
By signing this reference form, you confirm that you are the person listed as a reference (above) and are providing this recommendation based on your own knowledge and experience with the applicant.
Reference (Your) Signature*
Date*

MonthDayYear
Date
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