Leadership Reference Form - Southwestern College

Reference Form

Applicant Name*

First NameLast Name

How long have you known the applicant?*

In what capacity have you known the applicant?*

In your opinion, how well does the applicant qualify in the following areas:*

	Below Average	Average	Good	Very Good	Excellent	Top 1%
Intellectual Curiosity
Seriousness of Purpose
Motivation
Concern of Others
Leadership
Academic Achievement
Potential for Growth

Please describe in narrative form why you endorse this student as a nominee for the Leadership Southwestern Team. Be sure to address what you know about the student’s academic and professional experience, participation in extracurricular activities, and work in school, government and community service.*

Your Name*

First NameLast Name

Title*

Organizational Affiliation*

Daytime Phone*

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Privacy Policy
The information provided concerning the applicant will be kept confidential. Your information will not be shared with anyone outside of Leadership Southwestern.

Signature*

Southwestern College is committed to a policy of nondiscrimination on the basis of race, color, gender, age, religion, national origin, handicap, or other nonmerit reasons, in admissions, educational programs or activities, and employment, all as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of 1973, has been delegated to the vice president for business affairs, Christy Administration Building, Southwestern College, 100 College Street, Winfield, KS 67156-2499, (620) 229-6000. Southwestern College complies with the Crime Awareness and Campus Security Act of 1990. The yearly report is available from the dean of students upon request. Race and ethnic origin information is voluntary and will not be used in a discriminatory manner.

Applicant Information

Your Information

Authorization