Reference & Rating Referral Form

OF Layout Work

BACKGROUND:

You are receiving this 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 eligible 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.

Name

First

Last

Job Title

Phone

Name of Affiliated Organization/Institution

Organization/Institution Address

Address Line 1

Address Line 2

City

State

Zip Code

ABOUT THE APPLICANT

Applicant's Name

First

Last

Applicant's School Rank

Cumulative GPA

Relationship to Patient

APPLICANT RATING

Please select one rating in each category assess the following qualities of the applicant.

Capacity for Learning

Cooperatives

Is Dependable and Responsible

Attitude Towards Work (Work Ethic)

Leadership Abilities

LETTER OF RECOMMENDATION

Please provide supporting commentary below.

If additional character space is needed, you may send email to information@maryesmithfoundation.org. Please include the student's name & the word REFERENCE in the subject line.

Please Check Recommendation Overall Rating

Strongly Recommend
Recommend
Recommend with Reservations
Do Not Recommend

REFERRING PERSON ATTESTATION

By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please retain for your records as verification of your application.

Checkboxes

I agree

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.

Date / Time