El1is Hospital School ofNursing

1101Nott Street
Schenectady, New York 12308

(sr9) 243-4471
REQUEST FORREFERENCE

ON
PERFORIvIANCE AND POTENTIAL
Applicant's Name:
The appiicant named above is a candidate for admission to the Ellis Hospital School of Nursing. We would
appre.ciate your evaluation of the applicant's performance ancl potential for success in a prcgram leadiqg 1s 3
professional career in nursing. The information you provide will help the selection committee gain a better
nnderstanding of the applicant and assist with a decision to accept himlher into the school. The applicant
(h-#)Cflsrot) signed awaiver of theirrights of access to and review ofthis information. Applicants are
tsFcted in accordance wittr nondiscriminatory practices and with regard to the Ammicans with Disabilities Act.

Inrvhatcapaci8havr youknownthis applicant?

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How longhave youknown this applicant?

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What qualities/athjbutes does this applicant denooustrate that are consistent with yoru perception of a
profess-io',aiZ

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Please
app

in each categorybelow:
catesorv below:

Exceilent

Average

Good

Unsatisfactory

Attendarce
Performance

Attitude
Reliabilitv

Please PR-INT:

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ADDRESS:
SiGNATURE:

DATE:

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Please use the enclosed envelope to refum this form. Thank you

for your cooperation.

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