INSTRUCTIONS TO THE APPLICANT:
Print (or type) your full name and the name of your reference above and give this 3-page form to your reference person.
Your reference MUST return the completed reference form to you in a sealed envelope. The completed form is
required; he/she may include a separate letter of reference if he/she wishes. It may be mailed to you [provide a self-
addressed, stamped envelope] or hand delivered. The reference person must seal the envelope and sign across the
flap. You MUST NOT open the envelope.
Submit sealed references with your application packet which is due to the Department of Social Work Education by
January 31, 2018. DO NOT SEND SEPARATELY.
IMPORTANT NOTICE RE: APPLICANT’S RIGHTS:
In accordance with the Family Education Rights and Privacy Act of 1974, the California Information Practice Act of 1977,
and related policies and regulations, it is also understood that upon request, this letter will be made available to you
(the applicant/student) for examination. If you (applicant) wish to waive this right, please sign the waiver below.
I waive the right to see or inspect this form or any statement sent to the MSW program as a result of this request.
Signature______________________________________________________ Date_____________________________
TO REFERENCE:
The above named individual has applied for admission to the graduate program in Social Work for Fall 2018 semester
and listed you as a reference. The curriculum for this program is designed to prepare individuals for an advanced level
social work practice which focuses on the resolution of individual and social problems from a multi-systems perspective.
Students who successfully complete the requirements of this program are awarded the Master of Social Work (M.S.W.)
degree.
We seek the strongest candidates to maintain the standards of our profession in the service to our community and its
people. Accordingly, we firmly believe that it is unethical to admit applicants to the graduate program if their chance of
successful completion is doubtful and/or if they are not suited for this professional role. Please be aware that the law
requires that all student records, including letters of reference, be made available to the student for review upon
request unless the student has waived these rights. Thank you for your time.
REFERENCE FORM
Please return when completed
directly to the applicant