APPLICANT INFORMATION:
NURSING PROFESSIONAL REFERENCE FORM
Complete and Return to Admissions
Great Bay Community College
320 Corporate Drive, Portsmouth, NH 03801 (603-427-7632
gbadmissions@ccsnh.edu
Last Name First Name Middle Initial Date of Birth
I hereby waive any right to examine this evaluation. I understand that the information contained on this form will
be used to evaluate my application for admission to the above program of study. I realize that a waiver of my right
to access this evaluation is not a consideration of my admission. Please note: this form cannot be accepted without
applicant signature below. ❑ I AGREE to the above waiver ❑ I DO NOT AGREE to the above waiver
Applicant Signature Date
NAME PHONE EMAIL
COMPANY POSITION
How long have you known the applicant?
Relationship with the applicant? (please check only one box)
❑ Employer/Employee ❑ Professional/Client (eg. Clergy/Congregant, Doctor/Patient, Counselor/Client)
❑ Teacher/Student ❑ Other please describe
________________________________________________
If an employer, please complete this information:
Term of applicant’s employment: From / to /
Place of Employment Reason for leaving
Your thoughtful and fair assessment of this candidate’s qualifications and potential in their desired program of
study will be most useful in consideration for admission. On a scale of 1-5 please rate the applicant’s ability and
demonstrated competency in the following areas. Check the appropriate ranking with 1 being unsatisfactory and
5 being excellent.
Sets and achieves realistic goals
Exhibits a positive attitude
Works well under pressure
Is empathetic to other points of view
Cooperates with others
Comprehends oral and written instructions
Properly expresses self written and verbally
Is self-motivated and actively involved in the learning/working process
Demonstrates sound decision making skills and ability to problem solve
Referrer Signature Date
CHECK DESIRED SEMESTER:
❑ Fall 2021 ❑ Fall 2022 ❑ Fall 2023
1 2 3 4 5 1 2 3 4 5
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