Form PC-1532 Confidential Reference Form

OM6 10420-CW6
ExptaticnDam:

Confidential Reference Form
Applicant

If you have questions

Name:

or need an additional
reference form, call your
local recruiting office at
800.424.8580 (press W " at
the voicemail prompt).

Reference Name:
Company:
Address:
CilStateRip:

Phone Number:

..........................................................................................................................-............................................................................................................
Dear Friend of the Peace Corps:
The person named above has applied to become a Peace Corps Volunteer and has selected you to evaluate his or her qualifications. Please take a few moments to complete this reference form. The Peace Corps
appreciates your assistance.
The Peace Corps wasxreated to promote world peace and friendship by:
helping the people of interested countries in meeting their need for trained men and women;
helping to promote a better understanding of Americans on the part of the peoples served; and
helping to promote a better understandmg of other peoples on the part of Americans.
Serving as a Peace Corps Volunteer involves many challenges. It is not for everyone. Therefore, we would appreciate your honest appraisal of the applicant's qualifications to serve. No applicant is selected or rejected on
the basis of a single rating; supporting statements are obtained from many sources. Although you may know
the applicant in only one capacity, such as a supervisor, teacher, or friend, please try to respond to each section. There are several options for completing this form. Please check one:

a I will complete those sections of the form of which I have knowledge.
I will write and attach a letter. (Note: Please cover the zryformatzonthat is requested in thisfomn.)

a I do not know the applicant well enough to complete any section of this form.
Regardless of the option you choose, please return this form to the applicant within seven days. The evaluation process cannot be initiated until the applicant returns the reference form to the Peace Corps Placement
Unit in Washmgton, D.C.
After completing the reference form, place it in the envelope provided, seal the envelope, and sign your name
in the designated area over the seal. The applicant has been informed that tampering with the envelope will
result in disqualificationfrom Peace Corps service.

.........................................................................................................................................................................................
............,...................................
I am (was) the applicant's:
CI Job supervisor

from

to

Name of company

0 Employee

from

to

0 Friend

from

to

from

to

0 Teacher
from

to

0 Volunteer Supervisor from

to

0 Co-worker

Name of cganization

FGlS4? (Rev. lanOB)

C1 Other

Please specrn:

Section I: Motivation and Commitment
An applicant's personality and life goals should be consistent with volunteer service under challenging conditions.
Applicants should be willing to give of themselves. They should not have rigid or overly high expectations about
overseas service, and joining the Peace Corps should relate to their past experiences and future plans.
A.

From your knowledge, please give an example of a significant commitment that the applicant has fulfilled:

B.

Express your concerns, if any, about the applicant's ability to fulfill a commitment:

C.

Are you aware of any situations or problems the applicant may be
trying to avoid by going overseas as a Peace Corps Volunteer?

ONo

OYes

Ifyes, briefly explain:

Section 11: Work Skills and Knowledge
Peace Corps Volunteers must be able to use their skills and knowledge and transfer them to people overseas. This
includes setting goals, recognizing and solving problems, and effectively communicating with others. Volunteers must
also be able to i d e n m resources, which are often scarce, and use them appropriately.
A.

The kinds of experience listed below have proved to be useful indicators of successful performance as a Volunteer.
From your knowledge of the applicant, how well do you think he or she has performed each of the following:
1. Provided leadership/supervision
2. Worked under minimal supervision
3. Been a self-starter
4.

B.

Worked with limited resources and equipment

Not Applicable

Poorly

Adequately

Very Well

N/A
N/A
N/A
N/A

1
1
1

2
2
2
2

3

1

Describe how the applicant has demonstrated the above behaviors:

C. Express your concerns, if any, about the applicant's work-related skills and attitude:

(Previous editions of this tom,are ob8olek)

3
3
3

Section Ill: Social Sensitivity
Peace Corps Volunteers must be willing and able to observe, accept, or in some effective way cope with the ideas and
behaviors of others. They must also be able to adjust their own behavior within the framework of another culture/
society. This includes the ability to understand the experiences and problems of others.
A.

From your knowledge, how well do you think the applicant has demonstrated the following in his or her life:

Changed his or her behavior to accommodate others
2. Responded to the needs of others
3. Adapted to new customs
4. Worked with people of different backgrounds
1.

Not Applicable

Poorly

Adequately

Very Well

N/A
N/A
N/A
N/A

1

2

3

1

2

3

1

2

3

1

2

3

B.

Describe how the applicant has worked with people of different backgrounds:

C.

Express your concerns, if any, about the applicant's ability to work with diverse groups:

Section IV: Emotional Maturity
Peace Corps Volunteers are exposed to unfamiliar living conditionswithout the support systems that have provided them
security in the past. Their work requires that they respond appropriately to the needs of others, as well as their own.
A.

From your knowledge, how well do you think the applicant has demonstrated the ability to:
Not Applicable

Poorly

Adequately

Cope with stressful working and living situations
2. Cope with separation from family and friends
3. Develop friends and a support system in an
unfamiliar environment
1.

B.

Describe how the applicant has handled a difficult situation requiring any of the above abilities:

C.

Express your concerns, if any, about the applicant's emotional maturity:

Very Well

Section V: Additional Comments
A. .Describe notable abilities, interests, skills, or experiences of the applicant relevant to Peace Corps service:

B.

Describe any reservations you have about the applicant's ability to serve as a Peace Corps Volunteer:

Section W: Overall Recommendation
Please check one of the following to summarize your overall recommendation of the applicant:
0 I recommend the applicant without reservation as an excellent prospect for Peace Corps service.

rl On the whole, I recommend the applicant as a good prospect for Peace Corps service.
rl I have some reservations but feel that the applicant has a reasonable chance of success

in the Peace Corps. (Please explain in Section V above.)
0 I have substantial doubts about the applicant's suitability for Peace Corps service.

(Please explain in Section V above.)

Confidentiality Statement
The Privacy Act is a federal law that states that everyone has the right to know about and receive information about,
or copies of, documents about them that are maintained by the federal government. This law provides that the Peace
Corps may keep the identity of the source of this reference confidential only if you request that it be kept confidential.
Please indicate below whether you do or do not wish your identity revealed to the applicant.
0 I DO NOT authorize the Peace Corps to identify me as the source of this reference, nor do I authorize
the Peace Corps to release a copy of this reference in its entirety to the applicant. I realize that a summary
of this reference may be released without my approval.

5 I AUTHORIZE the Peretce Corps to identify me as the source of this reference and to

a copy d this

f?i&enm, upon request, to the applicant.

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