Confidential Reference Form
for CISV Leadership / Staff
Position
Confidential Reference Form for CISV Leadership / Staff Position
(The only official text for this form is this English edition)
1. Applicant’s information (To be filled in by applicant)
Given name Harina
Surname Marcia Devana
Number & street Jl. Ancol Selatan 1 No 45
Town / city DKI Jakarta / Jakarta Utara
Area / state / province Jakarta Utara / DKI Jakarta
Country Indonesia postcode / zip code
country code area code number
Telephone
Mobile phone +62 85920768286
Email
The applicant is seeking appointment as (tick correct position below):
Programme Director International staff Home staff
Leader √ Junior staff/leader Junior Counsellor
In the following CISV programme:
To be held in (indicate host CISV
country): Indonesia
Applicant has provided CISV programme and leadership role description to Reference
(Indicate Yes or No)
The reference is asked to please send the completed form to (please indicate contact name and details
needed for the person who must receive the completed reference form).
2. For reference to complete
Dear reference, the person named above has applied for a volunteer leadership position in a CISV
programme. He / she will work with international youth from several nations and cultural traditions.
During the CISV programme, the applicant will serve as a role model in our peace education activities
and work to create an environment where cross-cultural friendships and international cooperation are
possible. The applicant will be in a position of trust as friend, educator and guardian of the youth
participating in the CISV programme noted below. (CISV programme and position description describing
the duties relative to this application have been attached by the applicant.). Please complete the form in
English for international positions or, it can be in the language of Applicant for a position in that person’s
own country. CISV programme officials, the parents and the participating youth thank you for your
assistance in selecting appropriate personnel for CISV’s international peace education programmes.
Your response will be treated as private and confidential and destroyed as provided by law.
As a guide for the reference, CISV does not consider persons exhibiting the following behaviour to be
appropriate for a position of leadership: alcohol / drug abuse, serious criminal convictions, dishonesty,
emotional or behavioural disturbance, prejudice, sexual abuse, violence, lack of self-control, intolerance,
or the inability to appropriately deal with stress.
Reference is a member of CISV (Indicate Yes or No)
Reference has known the Applicant for 16 years
Reference sees / communicates with the often √ sometimes seldom
applicant (tick appropriate box):
Reference’s relationship with applicant (tick appropriate box)
Work supervisor Teacher/professor NA/Chapter CISV Official
Family friend √ Personal friend Student
CISV International (Valid from Page 1 of
Ltd Official Form 2008)
CISV member Co-worker Other (please specify)
CISV International (Valid from Page 2 of
Ltd Official Form 2008)
Reference’s information
Given name Yohanna Irina Nauli
Surname Siregar
Number & street Puri Beta 1, Pinus 2 no 61
Town / city Larangan Ciledug
Area / state / province Tangerang
Country Indonesia postcode / zip code 15154
country code area code number
Telephone +62 817118522
Mobile phone +
Email [Link]@[Link]
Name of applicant: Harina Marcia Devana
Position applied for: Leader
In my opinion, CISV would / would not (strike out or delete as appropriate) benefit by having this applicant
in a position of responsibility in its cross-cultural and international peace education programmes for the
following reasons:
Marcia used to be a teacher for past several years. She knows that education is
important nowadays especially in young learners. She might be responsible to be a
part of international peace education is CISV.
Special skills or other comments
She has responsibility of guiding young learners, ensuring their growth and development.
Declaration:
To the best of my knowledge, the information I have provided about the applicant is true, accurate and
complete. I am not aware of past/present behaviour by the applicant that would disqualify him/her from
working with international youth, acting as an appropriate role model or functioning in a position of trust
with CISV.
Reference’s signature
(day / month / year) 7/12/2023
Confirmation of previous reference:
Please sign here if you have provided the above reference for this applicant before and are confirming
that what was said in the previous Reference remains true and that your opinion on the matter has not
changed.
(day / month / year)
Reference’s signature
CISV International (Valid from Page 3 of
Ltd Official Form 2008)