Practical Training USA and Intern USA
How To Complete
The Reference Questionnaire
Please read before completing this form.
Dear Sir or Madam,
The person named on the reverse side of this form has applied for a Practical Training USA or Intern USA program
with CCUSA. Our trainee or internship programs provide an opportunity for the participant to receive professional
training in the USA for up to 12 month or 18 months (depending on the program) in a position related to their
education and/or applicable work experience and career pursuits. CCUSA can sponsor interns or trainees in the
following occupational categories:
• Hospitality and Tourism
• Information Media and Communications
• Management, Business, Commerce and Finance
• The Sciences, Engineering, Architecture, Mathematics, and Industrial Occupations
Your honest appraisal of this applicant will assist us in determining if the applicant has the skills, attitude and
determination to benefit from and contribute to this program.
This form has been given to you as someone who is familiar with the applicant’s personality and skills. We would
be grateful for your objective assessment of this applicant. If you do not think you are able to give an objective
assessment or if you are a personal friend or relative of the applicant, please do NOT complete this form.
If you are a suitable reference, please complete the form, adding any additional comments you think appropriate to
the situation. Your quick response is encouraged as we are unable to proceed with the application without your
reference. If you wish to share any reservations about the suitability of this applicant in private, please contact your
local CCUSA office.
Thank you!
Please return the Reference Questionnaire as soon as possible to the applicant.
Use the space below for additional comments.
Practical Training USA and Intern USA
Reference Questionnaire
Applicant Name CCUSA ID #
The information you provide is appreciated and will remain confidential.
Family members and peers—please do not complete this form.
PERFORMANCE EVALUATION
Please check the items for which you have sufficient knowledge about the applicant:
Excellent Very Good Fair Not Applicable/
Good Unable to Answer
1. Integrity
2. Work habits/organization
3. Adaptability/flexibility
4. Attitude
5. Relationship with co-workers
6. Leadership abilities
7. Ability to work in groups
8. Responsibility
9. Independence and self reliance
10. Maturity
11. Perseverance
OBJECTIVE RATING
Please comment below on the applicant’s suitability to the CCUSA Intern USA or Practical Training USA program:
What is your relationship to this person? Teacher Coach or tutor Priest/Minister/Rabbi Supervisor
Coworker They coach or tutor my child My child’s babysitter Employer
How long have you known this applicant?
Do you know of any reason why this applicant would be unsuitable to participate in this program? YES (if yes, please explain) NO
You may be contacted by CCUSA or an employer for verification of your reference for this participant.
Name of Referee Signature_________________________________ Date
Address Phone
COUNTRY CODE / CITY CODE
Company Position/Title
Email Mobile Phone
COUNTRY CODE
Please return this form to applicant at your ealiest convenience. Thank you for your evaluation!
Rev.06.12.19