UPEI MASTER OF NURSING PROGRAM
Academic Reference Form
For referees who are providing an academic reference
1. Applicant Information (please print):
Name: ___________________________________________________________
Mailing Address: ___________________________________________________
2. To the Referee: This evaluation will be kept confidential and will be used only for admission
purposes.
I have known the applicant as ☐ an undergraduate student, ☐ a graduate student, or ☐ in another capacity
(please specify): ____________________ for ________ years between the years of _________ and _________. I am
comparing this applicant to __________ students I have taught at the same level of study, in the past five years.
Please check the box that best reflects the academic qualities of the applicant.
Academic/Personal
Qualities
Outstanding
(top 5%)
Superior
(top 10%)
Above
Average
(top 25%)
Average
(top 50%)
Below
Average
Unable to
comment
Academic achievement
and aptitude
Problem solving/critical
thinking
Oral communication
Written communication
Research skills and/or
potential
Creativity
Ability to work
independently
Organizational ability
Initiative
Perseverance
Overall aptitude for
graduate study
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3. We also require your written comments on the suitability of the applicant for graduate study.
Please use the space below and attach an additional page, if desired. If you send an additional page,
please ensure that it is signed and dated.
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4. Referee Information (please print):
Name: _______________________________
Signature: __________________________
Position: ______________________________
Institution/Company: __________________
Mailing Address: _______________________ City: _____________
Country: ________________
Home Tel.: ______________
Province: ___________
Work Tel.______________
Date (dd/mm/yyyy): ______________________
Forward completed referee form to:
Admissions Office, University of Prince Edward Island
550 University Avenue, Charlottetown, PE, C1A 4P3
Fax: (902) 566-0795, Tel.: (902) 566-0439
Application Deadline
February 15
UPEI protects your privacy and maintains the confidentiality of your personal information. The information
requested on this form is subject to provisions of the UPEI Personal Information and Privacy Policy and is
collected under the authority of the Universities Act. If you have any questions about the collection of this
information, contact the School of Nursing, University of Prince Edward Island, 550 University Avenue,
Charlottetown, PE, C1A 4P3.
April 2013
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