Reference Form
Graduate Teacher Licensure (GTL) Program
This section to be filled out by the applicant.
 I hereby waive my right of access to this reference.
 I do not waive my right of access to this reference. (Please include a self addressed and
stamped envelope with this form.)
Applicant’s name: ___________________________
Tech ID: __________________
__________________________________________
Signature
________________________
Date
INTENDED PROGRAM (CHECK ONE):
 Teaching Certificate only (Post-Bac)
 Masters degree with teaching certificate (MAT)
WHERE DO YOU INTEND TO ATTEND THE TUESDAY EVENING EDUCATION CLASSES?
 MSU, Mankato Campus
 MSU 7700 France Campus in Edina
This section to be filled out by the reference.
1. I have known the applicant:
 less than one year
 one to two years
 more than two years
 casually
 fairly well
 very well
2. The applicant was (Check all that apply):
 student
in class
 volunteer
 employee
 colleague
 other (specify
_____________ )
3. Based on your ratings of the applicant (see evaluation form), please indicate your
recommendation below:
 I recommend the applicant without hesitation.
 I recommend the applicant with some hesitation (please explain in comment section).
 I do not recommend the applicant for admission to the graduate teacher licensure program
in Educational Studies: K-12 and Secondary Programs (explain in the comments
section).
4. In rating the applicant, please keep in mind the comparison group you indicate below:
 Undergraduate
 Master’s student
 Other (specify: ____________)
6/2010
NOTE: Applicants in all teacher licensure programs at MSU must document, at minimum, a satisfactory performance
on all of the dispositions. Listed below are the dispositions associated with professionalism. A disposition is a state of
mind that leads one to act in certain ways; dispositions are reflected through behaviors.
Minnesota State University, Mankato
Showing Professionalism
Student Name:
_______________
Commitment to
teaching and
professionalism
Responsibility
and work ethic
Integrity
Respectful relationships
Criteria
Unsatisfactory
Meets
Expectations
Exceeds
Expectations
Not
observed
SP1. Interacts with students, co-workers,
parents, and community in a positive,
professional manner
SP2. Perceives and respects the physical,
emotional, and social boundaries of
others
SP3. Perceives and respects diversity
among groups of people and
individuals based on age, ethnicity,
race, socioeconomic status, gender,
exceptionalities, language, religion,
sexual orientation, and geographical
area
SP4. Listens and values others’ ideas
SP5. Adheres to the guidelines for ethical
conduct as described by Minnesota Bd.
Of Teaching
SP6. Maintains confidentiality standards
SP7. Values and demonstrates honesty
SP8. Arrives on time and completes
assigned tasks on schedule
SP9. Accepts personal responsibility for
one’s own actions
SP10. Arrives ready and able to support
students’ intellectual, academic, social,
and emotional growth
SP11. Engages in professional growth:
reading, scholarly work, conferences,
workshops and further coursework
SP12. Uses proper grammar and
vocabulary in written and oral
communication
SP13 .Maintains personal hygiene
SP14. Dresses appropriately
Filled out by: ______________________________
Signature
Date: _____________
_____________________________
Printed Name
Please provide additional comments on the next page.
A member of the Minnesota State College and Universities System. MSU is an Affirmative/Action/Equal Opportunity University. This document is available in alternative format
to individuals with disabilities by calling the Office of Clinical & Field Experience at 507-389-1517(V), 800-627-3529 or 711(MRS/TTY).
6/2010
Additional Comments:
6/2010