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
First Name:
Middle:
Last Name:
Current Address
City
State
Zip
Mailing Address (if dierent)
City
State
Zip
Home Phone Number (555) 555-5555: Mobile Phone Number (555) 555-5555:
Email Address:
Community College:
Student’s Anticipated Major at a Four Year College
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© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. October 28, 2015
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Contra Costa
Diablo Valley
Los Medanos
P.O. Box 2643 Martinez, CA 94553-0264 www.kennedyking.org
Name and Title/Position of Reference (print)
Reference Signature in black or blue ink
Date
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3. Please use this page to provide us with any further information on the student you may have pertaining to any of the questions on the previous
page or any other information you think we should consider in for the student’s application.
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