Julia Platt Reference

Julia Platt Memorial Scholarship Reference Form

116 Union Street

Hamburg, NY, 14075

office@hamburgumc.org

www.hamburgumc.org

(716) 649-8080
Reference for / Applicant's Name:*

First NameLast Name
Your Name *

First NameLast Name
Relationship to Applicant*
Years Known*
Employer Name*
Job Title*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
2. Character Values

Please Rate how well the applicant exemplifies the following character traits? 4 being "Extremely Well" and 0 being "Not at all"

Has the candidates honesty and integrity ever been brought into question that you are aware of?*
How do you perceive the potential of this candidate to offer positive leadership in the future? How do you believe higher education will benefit this candidate for their future?
3. Disclaimer
I declare that to the best of my knowledge the information I have given in this reference is correct and complete.
Should be Empty:

Julia Platt Memorial Scholarship Reference Form