EMPLOYMENT REFERENCE FORM – ST. CROIX COUNTY UW Extension
4-H SUMMER ASSISTANT POSITION
RETURN TO:
St. Croix County UW Extension Office
DUE: March 4, 2016
1960 8th Ave, Suite 140, Baldwin WI 54002
Fax: 715-531-1930 or e-mail: heather.vierling@ces.uwex.edu
Your honest judgement of this applicant's qualifications for the position listed below would be appreciated.
The information will be handled in a confidential manner and will not be released to the applicant unless
you indicate your permission on this form.
Name of Applicant:
Date:
Position applied for:
Person Completing Reference:
Title:
Agency:
How long have you known the applicant?
Relationship to Applicant:
(co-worker, teacher, supervisor, friend, etc)
Please rate the applicant using the rating scale given here:
Far Exceeds
Above Expected
At Expected level
Below Expected
Not Satisfactory
Not Able to Judge
5
4
3
2
1
NA
Qualities Related to Job Success
Rating:
Personal Qualities That Affect Performance
Success in previous job(s)
Neat, well groomed appearance
Able to work with people
Tactful and courteous
Able to lead or inspire others
Enthusiastic
Oral communication skills
Dependability and promptness
Written communication skills
Maturity and poise
Completes assignments
Deals constructively with pressure
Organizes time & work
Flexibility/adaptability
Accepts guidance
Demonstrates honesty/integrity
Creative and innovative
Commitment to employer
Works independently
Potential for professional growth
OVERALL RATING OF THE APPLICANT FOR THIS POSITION
(Over)
Rating
Do you know of any reason why the applicant should not be considered for this
position with the University of Wisconsin-Extension?
Yes
No
If yes, please explain:
Would you employ this person to work under your supervision?
Yes
No
If no, please explain:
What would you consider this person’s strongest assets for this position?
What limitations (if any) does the applicant have for this position?
In your judgment, in what areas could the applicant benefit from additional professional development if
selected for this position?
Any additional information is appreciated and may be included here or on an attached sheet.
I believe this information is fair and accurate based upon my experience with the applicant. Please sign on
the line following this statement if you give permission to release information contained in the reference to
the applicant upon applicant request. No signature will imply lack of consent.
Signature:
Date:
University of Wisconsin, United States Department of Agriculture and Wisconsin Counties cooperating,
UW -Extension provides equal opportunities in employment and programming, including Title IX requirements.