BACHELOR OF NURSING (COLLABORATIVE) PROGRAM
Reference Form
Instructions: (1) Applicants: fill in your full name, date of birth and Memorial student number (if known). (2) Save the form and send
the link to your referee. (3) Referees: complete the entire form and save the file; (4) Attach the completed form in an email to
[email protected].
To save the form, do so by clicking on → File Save as...on the menu bar; ensure that you are saving the file in PDF format; and specify
where you would like to save the file, e.g. Desktop.
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*Notes a required field
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Do not type beyond the allotted space. This form is confidential when complete and submitted.
Section 1: Applicant Information
(LPN Bridging applicants – one reference regarding academic performance and one from a current employer or a practical nursing
faculty member regarding practical nursing clinical performance).
(All other applicants – ONE reference from an ACADEMIC source is required).
MUN No. (if known);
*Last Name:
*First Name:
Middle Name:
*Date of Birth (YYYY/MON/DD):
Section 2: Referee Information
The above applicant has applied for admission to the Bachelor of Nursing (Collaborative) Program and has given your name as a
referee. The purpose of this form is to obtain an assessment of the applicant's suitability for the Bachelor of Nursing (Collaborative)
Program. If you are unable to complete this reference by the deadline date of March 1 (LPN Bridging Option applicants are strongly
encouraged to apply by February 1), this applicant’s application will not be considered for admission.
*Last Name:
*Street 1:
*City:
*Postal/Zip Code:
*Email address:
*First Name:
Title:
Street 2:
*Prov./State:
*Country:
*Telephone no.:
Section 3: Referee Report
*How long have you known the applicant?
*In what capacity?
Please indicate your assessment of the applicant by marking an “X” in the appropriate spaces below.
Criteria
Initiative
Verbal communication skills
Written communication skills
Ability to work independently
Ability to handle responsibility
Problem-solving ability
Leadership qualities
Self-confidence
Excellent
Very Good
Good
Fair
Poor
Unable
to Assess
Section 4: Letter of Reference
Please use the space below to add any information you think will be helpful in our assessment of this individual's application.
*How would you recommend the applicant for admission to the Bachelor of Nursing (Collaborative) Program?
(1) Highly Recommend; (2) Recommend; (3) Recommend with Reservation; (4) Do Not Recommend
Section 5: Declaration, Signature and Submission of Form
I certify that the information contained in this form is complete and correct to the best of my knowledge. I understand that the
Nursing Consortium Office will verify documents submitted in support of a Bachelor of Nursing (Collaborative) Program application
and that the submission of falsified documents is considered a serious offence.
*I have read and agree with the above declaration (please indicate by writing YES in the field below):
*Last Name:
June 2014
*First Name:
Title:
*Date: