CMU, 500 Shaftesbury Blvd., Winnipeg, MB, Canada R3P 2N2 | Tel: 204.487.3300 1.877.231.4570 | Fax: 204.487.3858 | www.cmu.ca
SHAFTESBURY CAMPUS PERSONAL REFERENCE FORM
Dear Referee:
_________________________________ has applied for admission and possibly housing at CMU. As someone who
knows this applicant well, you have been asked to complete this reference form. We are seeking information that
will help us serve the student better as she or he enters the CMU community. This information will be kept in strict
confidence. Your prompt reply is appreciated. Thank you for your assistance.
1. How long, how well, and in what capacity have you known the applicant?
2. What contribution do you see this person making to the CMU community?
3. What potential difficulties might this person have at CMU?
4. Does this person have any special needs we should be aware of? Please specify.
CMU, 500 Shaftesbury Blvd., Winnipeg, MB, Canada R3P 2N2 | Tel: 204.487.3300 1.877.231.4570 | Fax: 204.487.3858 | www.cmu.ca
5. How would you rate this person in terms of the following characteristics?
(0-unknown; 1-very poor; 2-poor; 3-fair; 4-good; 5-excellent)
Rating Comments
Cooperation ______ ______________________________________________
Dependability ______ ______________________________________________
Physical health ______ ______________________________________________
Emotional health ______ ______________________________________________
Motivation ______ ______________________________________________
Oral skills ______ ______________________________________________
Academic ability ______ ______________________________________________
Leadership ______ ______________________________________________
Problem solving skills ______ ______________________________________________
Understanding of abilities/limits ______ ______________________________________________
Christian commitment ______ ______________________________________________
6. Additional comments: Some points on which you might comment include the applicant’s maturity, self-
evaluation, dependence/independence issues, home background, lifestyle, adaptability, inter-personal
relationships, church involvements, and vocational aptitude.
Name: _____________________________________ Phone: _____________________________
Address: ______________________________________________________________________________________
Occupation: ______________________________________ Email: ____________________________________
Signature: ________________________________________ Date: ____________________________
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