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Reference Form
Appalachian Scholars Program Application—Reference Form
Applicant's Name:
Name of Person Completing the Form:
How long have you known the applicant?:
Your Organization:
Email Address:
Telephone Number:
Fax Number:
Best days and times to call:
Please respond to the following questions about the applicant:
1. How will the Appalachian Scholars Award Program impact the student’s life and goals? :
2. Describe the applicant’s commitment to education, dedication, and motivation to succeed:
3. How would you describe the applicant with regards to personal characteristics such as independence, concern for others, values, and relationships with peers?:
4. Please cite examples which illustrate how the applicant distinguishes him/herself from other students? :
5. What is your opinion of the applicant’s ability to persist in college and complete a degree?:
6. Please rate the applicant on the following criteria.
Initiative:
Not Observed
Below Average
Average
Above Average
Exceptional
Oral Communication Skills:
Not Observed
Below Average
Average
Above Average
Exceptional
Written Communication Skills:
Not Observed
Below Average
Average
Above Average
Exceptional
Academic Performance:
Not Observed
Below Average
Average
Above Average
Exceptional
Resourcefulness/Ingenuity:
Not Observed
Below Average
Average
Above Average
Exceptional
Ability to Interact with Others:
Not Observed
Below Average
Average
Above Average
Exceptional
Self Discipline:
Not Observed
Below Average
Average
Above Average
Exceptional
Sense of Purpose:
Not Observed
Below Average
Average
Above Average
Exceptional
Leadership Ability:
Not Observed
Below Average
Average
Above Average
Exceptional
Civic Involvement:
Not Observed
Below Average
Average
Above Average
Exceptional
Motivation:
Not Observed
Below Average
Average
Above Average
Exceptional
Social Maturity:
Not Observed
Below Average
Average
Above Average
Exceptional
Reliability:
Not Observed
Below Average
Average
Above Average
Exceptional
Work Ethic:
Not Observed
Below Average
Average
Above Average
Exceptional
Ability to Real to to Other Cultures:
Not Observed
Below Average
Average
Above Average
Exceptional
7. What three words best describe the applicant?:
