AmeriCorps Reference Form

Reference Form
Name of Applicant Requesting Reference

First NameLast Name
The person requesting this reference is applying to be an AmeriCorps member in the Appalachia CARES Program (AmeriCorps State and National). To learn more about AmeriCorps, visit www.nationalservice.gov. To learn more about Appalachia CARES, visit www.clinchpowell.net.

The success of AmeriCorps largely depends upon an appropriate match between programs and members. Considerable value is placed on personal references during the application review and selection process. References will be evaluated by the Appalachia CARES program and placement site.

Your input is greatly appreciated.
Reference Name*

First NameLast Name
Position/ Title *
Organization/ Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
In what capacity have you known the applicant?*

Job supervisor / EmployerVolunteer supervisorHigh School teacherCollege instructor / AdvisorClergyCoachOther
Please describe the situation in which you know the applicant.*
Work Performance: Please comment on such qualities as the applicant's level of dependability, initiative, and ability to work with minimal supervision, independently, or as a member of a team.*
In your judgement, how competent is this applicant, as demonstrated by work in the community, in school, on the job, or in a position of responsibility? Please check one.*

Outstanding performanceAbove average performanceSatisfactory performanceBelow average performanceUnsatisfactory performance
Relationships with other People: AmeriCorps members must serve and communicate with people of varied cultural, economic, educational, racial, and religious backgrounds. Please comment briefly on the applicant's relationships with others and ability to work with a group.*
Emotional Maturity: Please comment on the applicant's ability to adapt and work under difficult and changing conditions.*
If you wish to provide further information about this applicant that is relevant to serving in AmeriCorps, such as desire to serve others, work ethic, flexibility, etc., please include that as well as any additional comments in this field.
What is your Overall Recommendation?*

I recommend the applicant for AmeriCorps service.I have some reservations, but I believe the applicant will succeed in serving with AmeriCorps.I do not recommend this applicant for AmeriCorps service.
Confidentiality Statement*

I AUTHORIZE the program and/or Corporation for National and Community Service to identify me as the source of this reference and to release a copy of this reference in its entirety upon request to the applicant.I DO NOT authorize the program and/or Corporation for National and Community Service to identify me as the source of this reference, nor do I authorize the release of a copy of this reference in its entirety to the applicant.
Signature*

Clear
Please sign using a mouse or touch screen
Date*

MonthDayYear
Date
Should be Empty: