Date

is requesting that you provide a letter of
reference regarding their admission to the Medical Laboratory Technology Program.
After completing the form, return it to the address shown at the end of the form.
Thank you for your valuable contribution.

I have known the applicant for ______years , ______months.

The circumstances under which I have known the applicant are:

 

Please place a check in the box that matches the rating you would give the
applicant on the following chart

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 MLT health care field
         
Ability to Get Along with Others
         
Dependability, Attendance
         

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

 

 

 

Please send form to:
Standards Committee
Medical Laboratory Technology Program
Lamar State College-Orange
410 Front Street
Orange, Texas 77630


Signature ___________________________________________________________________________


Name
Printed or typed

Position/Title ________________________________________________________________________

Address ____________________________________________________________________________