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AMERICORPS REFERENCE FORM
TO THE APPLICANT:
Please fill out the lines below and give this form to each of your references. Your reference
should complete this form, seal it in an envelope, sign his or her name across the seal on
the outside of the envelope and return it to you to include with the application you send to
AmeriCorps. If you have already submitted your application, have the reference return it
directly to us at the address below.
Applicant’s Name:
LAST FIRST MIDDLE
Address:
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET) CITY STATE ZIP CODE
Home Phone: Work Phone: ____
(AREA CODE) (AREA CODE)
Please return this completed and confidential reference form to:
Intermountain AmeriCorps
620 Lewis St
Wenatchee, WA 98801
The completed reference can also be sent via e-mail to:
anwenc@[Link]
or faxed to Anwen Cartwright at 509-662-1737
TO THE PERSONAL REFERENCE:
AmeriCorps engages more than 40,000 citizens in a year of full-time, results-driven service
sponsored by hundreds of local and national nonprofits. In return, AmeriCorps Members
earn education awards that help pay for college or pay back student loans. AmeriCorps
Members help communities meet critical challenges in the areas of education, public
safety, the environment, and other human needs.
The person named above is applying to be an AmeriCorps Member. The applicant has
indicated that you would be able to evaluate his or her qualifications and provide us with a
candid recommendation. The success of AmeriCorps largely depends upon an appropriate
match between programs and members. Considerable value is placed on personal
references during the application review and selection process. Your input is greatly
appreciated.
Name of Reference: _____
LAST FIRST MIDDLE
Position/Title:
Organization/Institution:
Address:
(IF P.O. BOX, ALSO GIVE NUMBER AND STREET) CITY STATE ZIP
CODE
Home Phone: Work Phone: _____
(AREA CODE) (AREA CODE)
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KNOWLEDGE OF THE APPLICANT
How long have you known the applicant? Years: _______ Months: ________
In what capacity have you known the applicant?
Job Supervisor/Employer
Clergy
Volunteer Supervisor
Coach
High School Teacher
College Instructor
Other (specify):____________________________
Please describe the situation in which you know the applicant.
WORK PERFORMANCE
1. Please comment on such qualities as the applicant’s level of dependability,
initiative, and ability to work with minimal supervision and as a member of a
team.
2. In your judgment, how competent is this applicant, as demonstrated by work
in the community, in school, on the job, or in a position of responsibility?
Please check one.
Outstanding performance
Above average performance
Satisfactory
Below average performance
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Non-satisfactory performance
RELATIONSHIPS WITH OTHER PEOPLE
3. AmeriCorps Members are required to understand other people’s viewpoints and
problems and to communicate with people from differing backgrounds. Please
comment briefly on the applicant’s ability to relate to others.
4. AmeriCorps Members must serve with other participants and with people of
varied cultural, economic, educational, racial, and religious backgrounds. How
would you rate the applicant’s working relationships with other people? Please
check one.
Works well with others; can lead or follow as the occasion demands.
Usually works well with others; can lead or follow in most situations.
Has average working relationships with others.
Has difficulty working with others.
Does not work well with others.
EMOTIONAL MATURITY
5. Please comment on the applicant’s ability to adapt and work under difficult and
changing conditions.
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6. AmeriCorps Members often serve in conditions of hardship and inconvenience.
They must be able to deal with new and changing living conditions, limited financial
resources, and considerable amounts of stress. With these considerations in mind,
how would you rate the applicant? Please check one.
Highly effective even in adverse situations and changing conditions.
Able to adapt to adverse situations and changing conditions.
About average in adapting to adverse situations and changing conditions.
May not be able to stand up well in adverse situations and changing conditions.
Completely unable to handle adverse situations or adapt to changing conditions.
ADDITIONAL COMMENTS AND SUPPORTING INFORMATION
7. If you wish, use additional paper to explain any of your ratings, and anything
else about this applicant that you feel is relevant to serving in AmeriCorps—such
as the applicant’s desire to serve others, maturity, work ethic, flexibility, and
dependability. Explain any reservations that you have regarding the applicant’s
participation in the AmeriCorps program to which he or she has applied.
OVERALL RECOMMENDATION
8. What is your overall recommendation?
I recommend the applicant without reservation as an excellent
candidate for AmeriCorps service.
I recommend the applicant as a good candidate for
AmeriCorps service.
I have some reservations, but I believe the applicant has a
reasonable chance of success.
I have some substantial doubts about the applicant.
I do not recommend this applicant for AmeriCorps service.
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CONFIDENTIALITY STATEMENT
I AUTHORIZE the program and/or the Corporation for National
Service to identify me as the source of this reference and to release a
copy of this reference in its entirety upon request to the applicant.
I DO NOT authorize the program and/or the Corporation for National
Service to identify me as the source of this reference, nor do I authorize
the release of a copy of this reference in its entirety to the applicant.
Your Signature:_________________________________________
PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED ACROSS THE
SEAL, DIRECTLY TO THE APPLICANT, OR FAX DIRECTLY TO THE
PROGRAM.
Please return this completed and confidential reference form to:
Intermountain AmeriCorps
620 Lewis St
Wenatchee, WA 98801
or faxed to 509-662-1737
If you have any questions please contact:
Anwen Cartwright
anwenc@[Link]
509-662-6156 ext 251