Reference Form Applicant for Professional Membership 51³Ô¹Ï Applicant Name(Required) First Last Your Name(Required) First Last Title(Required)Company/Institution(Required)Email Address(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCuba°ä³Ü°ù²¹Ã§²¹´ÇCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwanda¸éé³Ü²Ô¾±´Ç²ÔSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvalu°Õü°ù°ì¾±²â±ðUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Approximately how long, and in what capacity, have you known the applicant?(Required)Has the applicant established a satisfactory professional relationship with your institution?(Required) Yes No Does Not Apply Do you know of any instances in which the applicant received compensation from an institution or program for the placement of a client?(Required) Yes No Have you encountered any difficulties in working with the applicant?(Required) Yes No If there have been difficulties, what has been the nature of the problem(s)?To your knowledge, has the applicant ever visited your institution?(Required) Yes No Does Not Apply Based on your experience, please rate the applicant with respect to each category below.Familiarity with the Client(Required) Poor Fair Good Excellent Does Not Apply Familiarity with the Institution(Required) Poor Fair Good Excellent Does Not Apply Appropriateness of Recommendations(Required) Poor Fair Good Excellent Does Not Apply Fairness of Representation(Required) Poor Fair Good Excellent Does Not Apply Interpretation of Testing(Required) Poor Fair Good Excellent Does Not Apply Integrity(Required) Poor Fair Good Excellent Does Not Apply Please provide a reference statement addressing the applicant's strengths, professionalism, and ethics.(Required) 51³Ô¹Ï Members Only: If this applicant was mentored by you, please add a brief comment about that mentor/mentee relationship.Is there additional information you feel the need to share by phone?(Required) Yes No Signature (Type Full Name)(Required)By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.If you have any questions, please contact Caitlin Myers, 51³Ô¹Ï's Membership Manager, at [email protected]. Δ
