Please Return This Completed Form To Student in a Sealed Envelope For Submission Before 2/5/16.
• This electronic form allows you to download it to your computer, insert the requested information, save it on your computer, later modify and save answers.
• Print a hard copy once you have completed the form. Sign using black or blue ink
• Provide the signed hard copy in a sealed envelope to the requesting student.
• Alternatively you can print the downloaded form, fill it out and submit it using additional pages as needed. We prefer, if possible, that references be typed.
• Do not use the backs of pages or staple pages together.
• If you do fill this out in electronic form, we would appreciate you also sending an electronic copy by email to the Student’s Scholarship Counselor:
CCC MRodriguez@contracosta.edu, DVC scholarships@dvc.edu, or LMC toranje@losmedanos.edu. Label the attachment: student’s last name, first name
and “Reference UG KK.” (e.g. Doe_John_Reference_UGKK)
Student Information:
Your Feedback:
1. How Do You Know This Student? (Academic, personal, community).
2. What Is Your Opinion Of This Student With Respect To The Following?
A. Academic and Intellectual Potential
B. Financial Need
C. Community Service & Involvement
D. Personal Attributes, e.g., Character, Integrity, Responsibility, Commitment, Determination, Hard Work, Achievements,
Hardships Overcome & Life’s Goals
Mailing Address (if different)
Home Phone Number (555) 555-5555: Mobile Phone Number (555) 555-5555:
Student’s Anticipated Major at a Four Year College
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. October 28, 2015
P.O. Box 2643 ● Martinez, CA 94553-0264 ● www.kennedyking.org
Confidential
Undergraduate - Scholarship Reference Form
Name and Title/Position of Reference (print)
Reference Signature in black or blue ink
5
5
