Employer Reference Form

74 Harrison School Road
Grantville, PA 17028
717.865.2000
f: 717.865.0716
admissions@summitpa.org
summitpa.org
Employer Reference Form
This form should be completed by someone who is not related to the applicant. Please answer all questions to the best of your knowledge and return to the Admissions Office
at the address listed above. All information is kept confidential. Returning this form as soon as possible will help to accelerate the application process.
Applicant Information
Name of Applicant
Employer Information
Last Name First Name Phone Number
Address City State Postal Code
Email Address
Reference Information
How long have you known the applicant?
How well do you know the applicant?
slightly
casually
well
very well
How long has the applicant worked for you?
Please mark the best description of the applicant in the following areas:
Concern for Others: very caring considerate indifferent at times unconcerned not known
Cooperation: works well
with others
generally willing
to cooperate
avoids group participation does not work well
with others
not known
Desire to Learn Job: strong desire shows interest needs encouragement lacks interest not known
Diligence: very diligent somewhat diligent does only what is asked procrastinates often;
does not follow through
Emotional Stability: very stable stable but struggles at
times
not known
struggles emotionally emotionally unstable not known
Leadership Ability: excellent leader takes initiative to lead leads only when asked makes no effort to lead not known
Respect for Authority: very respectful generally respectful often critical disrespectful not known
Social Skills: excellent well adjusted introverted poor social skills not known
Work Ethic: outstanding very good good poor not known
Workplace Attitude: positive somewhat positive indifferent negative not known
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Reference (continued)
Briefly include any additional comments that may be helpful in determining whether the applicant should be accepted for enrollment
at Summit:
Please comment briefly on any personal character weaknesses that could pose a problem if this applicant became a student at Summit:
Please comment briefly on any strengths/abilities that would help this applicant as a student at Summit:
Would you recommend this applicant for enrollment to Summit?
Highly recommended Recommended Recommended, but with reservations Not recommended
If you have reservations or do not recommend this applicant, please explain:
Employer Signature
Signature:
Date:
Print Name:
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