AmeriCorps Online Reference Form

Reference Information

Applicant's Name

First Last

Reference's Name

First Last

Company/Organization

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Form Completion Options

Serving as an AmeriCorps member involves a significant commitment and many challenges. Therefore, we would appreciate your honest appraisal of the applicant’s qualifications to serve. Although you may know the applicant in only one capacity, such as supervisor or teacher, please try to respond to each section.

There are several options for completing this form. Please check one:

A. I will complete those sections of the form of which I have knowledge.
B. I do not know the applicant well enough to complete any section of this form.

Regardless of the option you choose, please complete this form within seven (7) days. The evaluation process cannot be initiated until the applicant returns the reference form to the Belleville AmeriCorps office. After completing the reference form, please submit it with the “Submit” Button at the bottom.

I am (was) the Applicant's

Job Supervisor	Company	Start Date	End Date

Volunteer Supervisor	Organization	Start Date	End Date

Co-worker	Company	Start Date	End Date

Employee	Company	Start Date	End Date

Teacher	School	Start Date	End Date

Other	Company/Organization	Start Date	End Date

Section I: Motivation and Commitment

An applicant’s personality and life goals should be consistent with volunteer service under challenging conditions. Applicant should be willing to give of themselves. They should not have rigid or overly high expectations about service, and joining AmeriCorps should relate to their past experiences and future plans.

From your knowledge, give an example of a significant commitment that the applicant has fulfilled:

Express your concerns, if any, about the applicant's ability to fulfill a commitment:

Section II: Work Skills and Knowledge

A. The kinds of experience listed below have proven to be useful indicators of successful performance as a member. From your knowledge of the applicant, how well do you think he or she has performed each of the following:

1. Provide leadership/supervision

Not applicable
Poorly
Adequately
Very well
Outstanding

2. Worked under minimal supervision

Not applicable
Poorly
Adequately
Very well
Outstanding

3. Been a self-starter

Not applicable
Poorly
Adequately
Very well
Outstanding

4. Worked with limited resources and equipment

Not applicable
Poorly
Adequately
Very well
Outstanding

B. Please describe how the applicant has demonstrated the above behaviors:

C. Express your concerns, if any, about the applicant's work-related skills and attitude:

Section III: Social Sensitivity

A. From you knowledge of the applicant, how well do you think he or she has demonstrated the following in his/her life:

1. Responded to the need(s) of others

Not applicable
Poorly
Adequately
Very well
Outstanding

2. Adapt to new customs

Not applicable
Poorly
Adequately
Very well
Outstanding

3. Worked with people of different backgrounds

Not applicable
Poorly
Adequately
Very well
Outstanding

B. Please describe how the applicant has worked with people of different backgrounds:

C. Express your concerns, if any, about the applicant's ability to work with diverse groups

Section IV: Additional Comments

A. Describe notable abilities, interests, skills or experiences of the applicant relevant to AmeriCorps service:

B. If applicable, please describe any reservations you have about the applicant's ability to serve as an AmeriCorps member:

Section V: Overall Recommendation

Please check one of the following to summarize your overall recommendation of the applicant:

I recommend the applicant without reservation as an excellent prospect for AmeriCorps.
On the whole, I recommend the applicant as a good prospect for AmeriCorps service
I have some reservations but feel that he or she has a reasonable chance of success in AmeriCorps. (Please explain in Section IV above.)
I have substantial doubts about the applicant’s suitability for AmeriCorps service. (Please explain in Section IV above.)

Confidentiality Statement

The Privacy Act is a federal law which states that everyone has the right to know about and receive information about, or copies of, documents about them which are maintained by the federal government. This law provides that Belleville AmeriCorps may keep the identity of the source of this reference confidential only if you request that it be kept confidential.

Please indicate below whether you do or do not wish your identity revealed to the applicant.

I DO NOT authorize Belleville AmeriCorps to identify me as the source of this reference, nor do I authorize Belleville AmeriCorps to release a copy of this reference in its entirety to the applicant. I realize that a summary of this reference may be released without my approval.
I AUTHORIZE Belleville AmeriCorps to identify me as the source of this reference and to release a copy of this reference, upon request, to the applicant.

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AmeriCorps Online Reference Form

Belleville AmeriCorps Applicant Reference Form

Reference Information

Form Completion Options

I am (was) the Applicant's

Section I: Motivation and Commitment

Section II: Work Skills and Knowledge

Section III: Social Sensitivity

Section IV: Additional Comments

Section V: Overall Recommendation

Confidentiality Statement

East St
Louis

Fire
Science

PSOP
Campus

Scott Air
Force Base

SW Justice &
Workforce Dev

Other
Campus