__________________________________[PRINT NAME] is applying for admission to the BSW Program at The University of North Carolina at Pembroke. The applicant will appreciate your completing this form and returning it to the Director of the Social Work Program. If you would rather write a letter, either in addition to or in place of this form, please free to do so.

According to the Congressional Family Educational Rights and Privacy Act of 1974, I hereby ____ do _____ do not waive my rights of access to any and all letters or statements of recommendation.

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Applicant’s Signature                                                                               Date

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1. Approximately how long have you known the applicant? ________ Years ________ Months

2. How well do you know the applicant? ____ Thoroughly ____ Somewhat ____ Little knowledge

3. What is or was your relationship to the applicant?

____ Instructor ____ Employer ____ Co-Worker ____ Minister ____ Other ________________________

4. Please rate the applicant in the following areas by using the following rating scale:

5. Do you have any information related to character and temperament that would have an impact on the applicant’s ability to be an effective social worker? Please include positive or negative comments on the back of this form.

6. Level of recommendation:
 

_____________________________  ________ _________________________________
Signature of Reference                                                   Date                 Place of employment

_____________________________________ __________________________
Print Name                                                                                     Phone Number

Return this form to: