*First Name *Last Name *Phone Number *Email *Applicant First Name *Applicant Last Name *How long have you known the applicant? *In what capacity do you know the applicant? *What can you share about the applicant’s skills and abilities? *What can you share regarding the applicant’s character and personality? *Would you recommend the applicant as a CPE intern for our program? YesNo *What can you share about the applicant’s areas for improvement? *If you or a loved one were hospitalized, would you welcome a chaplain visit from this applicant? Why/ why not? *Please share any additional comments you think we be helpful as we consider this applicant. *Signature