RADIOLOGIC
TECHNOLOGY
DEPARTMENT
Letter of Reference
Form
Application for Admission
Note to applicants:
This form should be copied by you and
sent to the references you wish to use for applying to the program.
To those providing references:
Please provide the information below regarding the person requesting your reference for entry into the Missouri Southern State University Radiologic Technology program. When completed, please return it directly to the address below in a sealed envelope to:
Missouri Southern State University
ATTN: Director of Radiologic Technology Program
3950 E. Newman Road
Joplin, MO 64801-1595
| Date: Name of prospective student: Name & title of person providing reference: Company name (if applicable): Address: City, State, Zip: Phone Number: E-mail: How long have you known prospective student? In what capacity have you dealt with him/her? |
__________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ |
| Please rate this
person on the following characteristics by checking the appropriate
number: Rating scale: 4 (superior), 3 (above average), 2 (average), 1(below average), 0 (sub-standard ), NA (unable to provide accurate input on this characteristic) | |
| 1. Punctuality | 4__ 3__ 2__ 1__ 0__ NA__ |
| 2. Maturity | 4__ 3__ 2__ 1__ 0__ NA__ |
| 3. Self-motivation |
4__ 3__ 2__ 1__ 0__ NA__ |
| 4. Academic skills |
4__ 3__ 2__ 1__ 0__ NA__ |
| 5. Study habits |
4__ 3__ 2__ 1__ 0__ NA__ |
| 6. Work ethic |
4__ 3__ 2__ 1__ 0__ NA__ |
| 7. Ability to receive constructive
criticism |
4__ 3__ 2__ 1__ 0__ NA__ |
| 8. Interpersonal skills |
4__ 3__ 2__ 1__ 0__ NA__ |
| 9. Empathy for others | 4__ 3__ 2__ 1__ 0__ NA__ |
|
This person's greatest attribute is: Area's for improvement:
| |
