Reference Form - Phoenix College Medical Laboratory Science (MLT) Program
Applicant Instructions: T
his reference is required to complete your application. It must come from an employer who
knows you well and can comment on your academic ability, employment skills and your suitability and preparation for a
career in Medical Laboratory Science. If you do not have an employer, you can use an instructor who has known you for
more than one semester.
Please give the form to your designated reference, providing him or her with instructions to email the completed reference
form to
: rochelle.helminski@phoenixcollege.edu
nces provided in confidence are often of greater value in assessing an applicant’s qualifications. Please read the
statement below and indicate your preference with regard to the confidentiality of this evaluation.
In accordance with the Family Educational Rights and Privacy Acts of 1974 (Public Law 93-380), I understand that
I have the right of access to this reference but may choose to waive that right. My preference is noted below:
___ I waive my right of access to this reference form
___ I do NOT waive my right of access to this reference form
Applicant’s name (please print) ____________________________________ Student ID # ________________
Evaluator Instructions: Please complete the following information and email directly to the Phoenix College Program
Director following the directions provided.
Name _________________________________________ Title/Occupation ____________________________________
Address __________________________________________________________________________________________
Street City State Zip
Phone (_____)_____________________
How long have you known the applicant as an employee?: ________________
In what capacity? (check all that apply): _______Employer _______Supervisor _____Instructor
Please indicate your evaluation of the applicant with a check mark:
Excellent Good Average Below Average Not Observed
Time Management
Critical Thinking/Judgement
Emotional Maturity
Interpersonal Skills
Reaction to Criticism
Personal Integrity/Honesty
Overall Evaluation
erall recommendation for admission to the Medical Laboratory Science Program:
____ I recommend the applicant with no reservation.
_____ I recommend the applicant with some reservations.
_____ I do not recommend this applicant.
Additional comments optional. You may attach a separate sheet.
Signature _________________________________________________________ Date __________________________
This form must be emailed NO LATER THAN September 4, 2020 to:
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