Form PCR Professional R PCR Professional R 2105-A

OMB Control No. 0420-xxxx

Expiration Date: xx/xx/20xx

Reference Form for Peace Corps Response Candidates

(Professional)

Date:

Applicant Name

Peace Corps Response Country:

Project Applied for:

Project Description

Reference

Name: Phone Number:

Relationship to Applicant:

1. How long have you known the applicant? Do you feel you know the applicant well enough to make a recommendation

2. How does the applicant work under minimal supervision and with limited resources/equipment?

3. Do you have any concerns about the applicant's work-related skills and attitude?

2. How were the applicant’s interpersonal skills in the context in which you interacted with him/her?

2. From your knowledge of the applicant, how would you comment on this individual’s ability to manage stressful situations?

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

Final recommendation

Please check one of the following that best describes your final recommendation:

a. Recommend without reservation as an excellent applicant. ______

b. Recommend as a good applicant. _______

c. Recommend as a fair applicant (some reservations). _______

d. Not recommended. _______

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

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.

□ 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.

□ I AUTHORIZE the Peace Corps to identify me as the source of this reference and to release a copy of this reference, upon request, to the applicant.