Office of Global Initiatives
170 North St/Box 139
Dryden, NY 13053 USA
Email: global@tompkinscortland.edu
www.tompkinscortland.edu/global
Study Abroad Confidential ACADEMIC Reference Form
STUDENT Name (Last, First, Middle) Program Location Abroad Primary SUNY Campus Student ID
Please submit this reference form to the office above
To the Student and Whomever Completes the Reference:
The ACADEMIC REFERENCE should be given to a former or current professor who knows the student well and is able to judge
their academic and personal maturity as it relates to study abroad. Faculty leaders of the trip you are applying to participate in
SHOULD NOT compete this form. A letter of recommendation is acceptable in lieu of this form..
Where to submit: As this letter is confidential, it should be sent it directly to the Office of Global Initiatives: Attention: Study
Abroad by the person completing the reference. (If mailing you must provide them with a self-addressed stamped envelope for
this purpose. You may submit it yourself if it has been placed in an envelope and signed over the seal by the person who
completed it.
I waive my right to access this reference completed by ____________________________________________
Yes No
Name of Reference
Student's Signature:_______________________________ __________________Date:___________________
The student named above is applying for the designated study abroad academic program. We would appreciate your assessment
of the applicant's attributes with which you are familiar. You may write comments on the back OR submit a letter of
recommendation for the student.
How long and in what capacity have you known the student?__________________________________________________
Academic attributes Excellent Very Good Good Fair Poor No Evaluation
Competence in major or specialization
Academic interest and motivation
Capacity for independent study
Resourcefulness
Reliability
Integrity
Non-academic attributes
Excellent Very Good Good Fair Poor No Evaluation
Level of maturity
Ability to adapt to new circumstances
Self-confidence and self-esteem
Ability to relate well to others
Emotional stability
Open-mindedness
Integrity
Please state frankly your opinion of this candidate's ability to suitably represent both their home campus and the USA in a
Study abroad program, weighing both strong and weak points. Please use the space on other reverse side of this page. You may
also add or attach a letter of recommendation.
Your Name (please print)__________________________________________Title, Department:_______________________
Signature: ________________________________Date:_________________Institution:______________________________
(Comment on next page if desired)
