I authorize (name of your reference writer) ________________________________________________ to provide information related to my grades/
GPA, character traits or other personally identiable information from my education to the NSE Coordinator for the purpose of assisting me in
obtaining acceptance to the National Student Exchange Program.
In compliance with the Family Education Rights and Privacy Act of 1974, you may have access to this reference unless access is waived by complet-
ing the following statement:
I (applicant’s name), ____________________________________________________, waive my right to access this reference.
Student’s signature________________________________________________________________________________ Date ___________________
In what capacity does this reference writer know you? q Advisor q Classroom Instructor q University Sta Member q Other
Applicant: Please Complete Top Section
The National Student Exchange provides a student with the opportunity to attend another university within the United States for up to one year. In making decisions on the
appropriateness of a student’s participation in the exchange, we need to know about his/her motivation, adaptability, academic skills and those personal qualities that will give
the student the ability to benet fully from the exchange experience. While we will appreciate any observations that will assist us in evaluating the applicant, of special interest
are qualities such as competence, independence, assertiveness, resourcefulness, quality of performance, condence, social skills, open-mindedness and integrity.
Evaluator: Please Complete This Section
I. How well do you know the applicant? (Check the most appropriate response.)
q Extensive contact in a variety of settings
q Well acquainted in classroom or campus environment
q Limited contact in classroom or campus environment
q Academic Advisor
q Other: ______________________________________________________________________________________________________________
2. In comparison with other students whom you have known at comparable stages of their careers, please rate the applicant in these
areas. (Check the most appropriate response.)
Excellent Very Good Average Below Average Unable to Judge
Academic Ability q q q q q
Maturity & Self-Condence q q q q q
Cooperation & Adaptability q q q q q
Initiative & Motivation q q q q q
Social Skills q q q q q
Independence q q q q q
Integrity q q q q q
– over –
National Student Exchange Reference
Name of applicant ____________________________________________
Minnesota State University Moorhead is an equal opportunity educator and employer and is a member of the Minnesota State Colleges and Universities System.
This information will be made available in alternate format upon request by contacting
Disability Services at 218.477.4318 (voice) or 1.800.627.3529 (MRS/TTY).
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3. Exchange to another campus would be appropriate for the applicant: q Yes q No
4. Remarks: Based on your knowledge of the applicant, please comment on his/her chances for success and what would be gained from
an exchange experience.
Signature _____________________________________________________ Printed Name _______________________________________________
Position ______________________________________________________ Telephone __________________________________________________
Janet Hohenstein, NSE Coordinator • CMU 120 • Minnesota State University Moorhead • Moorhead, MN 56563
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