Character Reference Form

Please complete the form below to provide a character reference.

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Section 1: Reference Provider Details

Name *

First

Last

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email *

Part Name Part

Relationship to Applicant

How long have you known the Applicant?

Section Part 2: Applicants Details

Full Name of Person You Are Recommending *

Section Part 3: Character Information

Please tick the traits you believe best describe the applicant *

• Honest
• Trustworthy
• Respectful
• Good Listener
• Caring
• Discreet
• Responsible
• Good Communicator

Give a short example or explanation showing how the applicant has shown these traits *

Section Part 4: Community Role Suitability

In your own words, explain why you believe this person is suitable *

Section Part 5: Declaration

Signature/Autograph *

Printed Name *

Date / Time *

Date

Time

Section Part 6: Contact Permission

Contact Permission *

• I agree to be contacted to verify this reference.
• I do NOT agree to be contacted.

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