Pharmacy Technology Reference Request

Date _______________

____________________________________________ is requesting that you provide a letter of reference regarding his/her admission to the Pharmacy Technology Program. After completing this form, please return it to the address shown at the end. Thank you for your valuable contribution.

I have known the applicant for ______ years, ______ months.

The circumstances under which I have known the applicant are:
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On the following chart, please place a check in the box of the rating you believe is representative of this applicant.

Personal Attributes	Exceptional	Above Average	Average	Below Average	No Information
Intellectual Capacity
Writing Ability
Oral Communication Skills
Problem-Solving Skills
Intellectual Curiosity
Motivation to Learn
Perseverance in Adversity
Likelihood of Success in the Pharmacy Technology health care field
Ability to Get Along with Others
Dependability, Attendance

Please add any comments that would assist faculty members in the decision of admitting the applicant to the Pharmacy Technology Program. (If more space is needed, attach an additional sheet.)

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Please send form to:

Standards Committee
Pharmacy Technology Program
Lamar State College-Orange
410 Front Street
Orange, Texas 77630

Signature ___________________________________________________________________________

Name (printed or typed) _______________________________________________________________

Position/Title ________________________________________________________________________

Address ____________________________________________________________________________