School of Nursing - Kentucky State University

Reference Request Form (continued)Applicant’s Name: ___________________________________________________________________________Last First MIWrite a short narrative description of your overall impression of the applicant:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How long have you known the applicant? _________________________________________________In what capacity? ___________________________________________________________________Overall recommendation: (Please check the appropriate statement.)[ ] Highly Recommend [ ] Recommend[ ] Recommend with Reservation [ ] Do Not Recommend* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *TO BE COMPLETED BY PERSON PROVIDING REFERENCE (Please Print)Name _____________________________________ Job Title (if applicable) ____________________________Name of Agency: ____________________________________________________________________________Address: ___________________________________________________________________________________Street Address City State Zip(_____)___________________________________________________________________________Telephone NumberSignature ___________________________________________ Date ________________________Please return this completed form to:Nursing Admission CommitteeSchool of NursingKentucky State University400 East Main StreetFrankfort, KY 40601Please note: The School of Nursing deadline for receiving this completed Reference Request form is 5:00 PM on May 1st.It is the policy of Kentucky State University not to discriminate against any individual in its educational programs, activities, or employment on thebasis of race, color, national origin, sex, disability, veteran status, age, religion, or marital status. Kentucky State University is an Equal Educational andEmployment Opportunity/Affirmative Action Institution.Revised March 2013