RECOMMENDATION REPORT FOR

MONE EDUCATIONAL SCHOLARSHIP APPLICANT  

Name of Applicant:                                                                                                                                                                                          
                                Last                                  First                            Middle                    Maiden
                         
By signing this form, I waive my right to review this document:

__________________________________     
Signature of Applicant
 

TO THE RECOMMENDER:

The applicant listed above has selected you as a reference for a MONE Scholarship.  The purpose of the scholarship
program is to assist MONE members in obtaining an educational degree and advancing their skills and expertise in
contemporary practice.  Scholarships may be used for tuition or research expenses.  We are interested in obtaining
information you think would be helpful in assessing this applicant's qualifications for receiving a scholarship.  This
recommendation will be held in strict confidence during the application procedure. Upon completion of the application
procedure, this letter will be destroyed.


SUMMARY EVALUATION:
Rank applicant on each of the following items:  

                                                OUTSTANDING              AVERAGE              BELOW AVERAGE

Perseverance in pursuing goals         q                   q                 q

Seeks professional development         q                   q                 q

Creativity            q                   q                 q

Demonstrates leadership potential  q                   q                 q

Communication skills                         q                   q                 q

Analytical/problem-solving skills   q                   q                 q

Describe the applicant's strengths in relation to his/her scholarly or creative potential:

In what areas will this applicant need to strengthen skills or abilities? 

Indicate dates you were associated with this applicant 
from _________ to ________                                                    
      mo/yr              mo/yr

Capacity in which you knew the applicant (circle one):
MONE member              advisor/faculty                                          employer                       other (explain)
 

RECOMMENDATION
q               4.  Highly Recommend
q                3.  Recommend
q                2.  Hesitate to Recommend
q                1.  Do Not Recommend

Signature of respondent:                                                     Date:                              

Name of respondent:      ___________________________     Phone:                           

Title of respondent:        ___________________________________________________

Institution/Employer:      ___________________________________________________

Address of respondent:   ___________________________________________________

RETURN THIS FORM TO: 
Michigan Organization of Nurse Executives
c/o Michigan Health & Hospital Association
6215 West St. Joseph Highway
Lansing, MI  48917
INQUIRIES CALL:  (517) 323-3443

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