Academic Reference Form
To be completed by the applicant:
Applicant name:
Student ID number (if applicable):
Subjects and/or courses interested in tutoring:
We appreciate your sincerity in describing the applicant’s suitability to work as a tutor in the
subject area or courses listed above; the information you provide is confidential and will not be
revealed to the applicant. Please complete and return this form immediately. Applicants are not
considered until their references are received and their application files are complete.
Date:
Name:
Title, Institution/Company:
Address:
Phone number:
How long have you known the applicant?
In which subjects have you taught the applicant?
How would you rate the applicant on the following attributes?
Subject/course expertise (relative to their level of study)
Outstanding
Good
Average
Below Average
Poor
Insufficient Knowledge
Additional comments:
Communication (oral and written)
Outstanding
Good
Average
Below Average
Poor
Insufficient Knowledge
Additional comments:
Academic skills (academic honesty, attendance, assignment timeliness, response to feedback,
problem solving, etc.)
Outstanding
Good
Average
Below Average
Poor
Insufficient Knowledge
Additional comments:
Interpersonal skills (collaboration, respect for others, patience, leadership, etc.)
Outstanding
Good
Average
Below Average
Poor
Insufficient Knowledge
Additional comments:
Any overall comments on the applicant in question are welcome:
Do you consider the applicant of proven capacity to work with someone who has a learning,
mental, or physical disability?
yes no
Please explain:
Signature: ___________________________________
After completing the Academic Reference form, please:
1. Mail it to the address below, or
2. Email it to the address below, or
3. Place it in a sealed envelope and sign across the sealed flap, then return it to the
applicant to submit
To submit your reference form, or for additional information, contact Janet Klippenstein,
Learning Services Coordinator:
Student Life & Learning, HA 114
Concordia University of Edmonton
7128 Ada Blvd, Edmonton, AB
T5B 4E4
phone: 780.479.6854
toll free: 1.866.479.5200 ext 241
email: janet.klippenstein@concordia.ab.ca
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