CONFIDENTIAL LETTER OF REFERENCE
This letter of reference should be filled out by a referee under whom the applicant has studied or by someone who has supervised the
applicant in work related to the proposed field of study. Your evaluation will be most helpful and will be kept in strictest confidence. Please
return this form in a sealed envelop with your signature across the sealed flap.
NAME OF APPLICANT
___________________________________ _____________________________________________ ___________________
Family Name First Name(s) Middle Name
NAME OF REFEREE
____________________________ ________________________ ____ _____________ _________________________
Family Name First Name(s) M. I. Title Rank or Position
INSTITUTIONAL AFFILIATION OF REFEREE
Name of Institution ________________________________________________________________________________________
Address _______________________________________________________________________________________________________
Email Address _____________________ Office Telephone Number________________________________________
How long have you known the applicant? _____________________Years ______________________ Months
In what capacity have you known the applicant? Please place an X-mark on the appropriate box(es) below.
_______Teacher ( High School / Undergraduate) _________Academic Adviser
_______ School principal / Dean _________ Guidance Counselor
PLEASE PROVIDE A BRIEF CANDID EVALUATION OF THE APPLICANT. Your statement will be given considerable importance and should,
therefore, be as complete and detailed as possible. Some areas which may be covered are applicant’s scholastic ability, strengths and
weaknesses in terms acquiring a college degree, his/her definition of objectives and goals as they relate to his/her plans for BS Medical
Technology and other factors that might assist ICLS in considering the applicant.
_______________________________________________________________________________________________________________
IN THE RATING CHART BELOW PLEASE EVALUATE THE APPLICANT IN COMPARISON WITH OTHER STUDENTS WHOM YOU HAVE
KNOWN DURING YOUR PROFESSIONAL CAREER. Place an X – mark inside the appropriate boxes. If you are unable to evaluate the applicant
in a particular item, please mark the boxes under NA.
Evaluation Parameters Excellent Very Good Good Fair Poor Very Poor NA
(95-100%) (85-94%) (70-84%) (50-69%) (40-49%) (<40%)
Seriousness of Purpose
Motivation to Achieve Degree
Intellectual Ability
Study / Work Habits
Capability for Independent
Study
Stewardship / Resourcefulness
and Initiative
Emotional Maturity
Adaptability to New Situations
Oral Communication (English) /
Ability to orally present reports
Written Communication
(English) /
Ability to write reports
Leadership Qualities
Teaching Potential
Willingness to work with a
group
Honesty and Integrity
Courtesy and Politeness
Faithfulness and Obedience
GENERAL RATING OF APPLICANT
______Excellent ______Above Average ______Below Average
______Superior ______ Average ______Poor
The rating was done to the best of my knowledge and experience with the applicant as attested by my signature below.
______________________________________________ _____________________________
Signature Date
_____________________________________________
Printed Name of Referee
