Common Confidential Reference Form 2013
For admission to tertiary accommodation
This reference is important in the selection process so full and frank comments are appreciated. Reference forms must be submitted by
1 October 2012 to enable the applicant to be considered in the first round of offers.
This reference is being requested on the understanding that it will remain confidential to those concerned with considering applications for the
types of accommodation specified by the applicant and will not be used for any other purpose. The NZ Official Information Act 1982 and the NZ
Privacy Act 1993 protect evaluative material and allow the accommodation service the ability to decline to supply a copy of such material when
requested by other parties.
Applicant information
Family name:
Given names:
Date of Birth: dd / mm / yyyy
Gender:
Male
Female
Referee information
Name of referee:
Position held:
School/organisation:
School/organisation address:
Fax number:
Telephone number:
Email address:
About the applicant
Please tick the most suitable grade and make comments to support your grading.
Attitude to independent study/self-discipline/time management skills
Outstanding
Comment:
Above Average
Average
Below Average
Poor
Below Average
Poor
Ability to relate to and show concern for others
Outstanding
Comment:
Above Average
Average
Personal behaviour and social maturity (including attitudes to alcohol and drugs)
Outstanding
Comment:
Above Average
Average
Below Average
Poor
Self confidence/self-reliance/adaptability to new situations
Outstanding
Comment:
Above Average
Average
Below Average
Poor
NSN:
Academic ability
Outstanding
Comment:
Above Average
Average
Below Average
Poor
For New Zealand Schools Only (please tick, as appropriate)
Anticipated overall Level 3 NCEA or other Year 13 qualifications
Mostly Excellence
Mostly Merit
Mostly Achieved
Other If Other, please specify :
Anticipated International Baccalaureate (IB) grade
Below 30
30-34
35-40
Above 40
Anticipated Cambridge International Examinations (CIE) grade
Mainly A Level
UCAS Tariff Score:
Mainly AS Level
280 or above
Even Split
250-270
210-240
170-200
130-160
120
Anticipated overall scholarship outcome, if applicable
Outstanding
Achieved
Student Support
Are there any concerns / special needs that we should be aware of so that appropriate support can be provided?
(eg health problems, home situation, disability, eating disorders)
The applicant’s suitability for tertiary accommodation
Please tick one of the following
Highly Recommended
If Other, please specify:
Recommended
Recommended with reservations
Other
Additional Comments (please complete) ie contribution to school
I declare that the information I have provided in this Common Confidential Reference Form is correct.
Signature:
Date:
DD /
MM /
YY
less than 120
Tertiary institutions
Please indicate the institutions below to which the applicant would like to be considered by
Institution
Send to (please tick)
Contact details
The University of Auckland
Email to [email protected] or fax 09 373 7552
Auckland University
of Technology
Accommodation Services, Wellesley Student Apartments and Akoranga
Student Village, 8 Mount Street, Auckland 1010
[email protected]
University of
Canterbury
Accommodation Office, Private Bag 4800, Christchurch 8140
[email protected] (email preferred)
Lincoln University
Accommodation Services, PO Box 84, Lincoln 7647, Canterbury
[email protected]
Manukau Institute of
Technology
Residential Manager, Student Village, Private Bag 94006,
South Auckland Mail Centre, Manukau 2241
[email protected]
Massey University (Albany)
Accommodation Office, Private Bag 102904, North Shore Mail Centre,
Auckland
[email protected]
Massey University (Palmerston North)
Halls Community Manager, Private Bag 11222, Palmerston North 4442
[email protected]
Massey University (Wellington)
Accommodation Office, PO Box 756, Wellington 6140
[email protected]
Unitec
Accommodation Manager, Private Bag 92025, Auckland Mail Centre,
Auckland 1142
[email protected]
Victoria University of Wellington
Accommodation Service, PO Box 600, Wellington 6140
[email protected]
The University of Waikato
Accommodation and Conference Services, Private Bag 3105,
Hamilton 3240
[email protected]
Please send this form to each institution indicated above by 1 October 2012, or for The University of Auckland first round offers, 15 September 2012.
Please remember to keep a copy for your files.