Pastoral Reference Form Pastoral Reference Form Step 1 of 2 50% Dear Pastor, The person named below has applied to join our internship program in Jerusalem. We would be grateful if you would complete this form of reference. Please feel free to contact us with any questions you may have. Thank you very much! Name of applicant* First Last Please specify the person for whom you are providing a reference.Applicant's email address* Your Name* First Last Your email address* Name of your church/congregation* Address of your church/congregation* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone number of your church/congregation*Email address for your church/congregation How long have you known the applicant?* How well do you know the applicant?* Very Well Fairly Well Casually By Name, Sight Please describe the applicant’s level of involvement in your church/congregation (check all that apply):* Attends Regularly Involved Enthusiastic Cooperative Attends Irregularly Has the applicant served your congregation in any capacity?* Yes No Please give a brief description:*What are the strengths and spiritual gifts of the applicant according to your observations?*What is your assessment of the applicant’s weaknesses?* What is the applicant’s effect on his/her peers?* Positive Neutral Negative Unknown Are there any complex family, relational or emotional factors which might affect the applicant’s service with us?* Yes No Please explain:*Please try to assess the following based on your knowledge of the applicant:Spiritual Maturity* Uncertain Weak Fair Good Very Good Outstanding Devotion to Christ* Uncertain Weak Fair Good Very Good Outstanding Personal Integrity* Uncertain Weak Fair Good Very Good Outstanding Self-Discipline* Uncertain Weak Fair Good Very Good Outstanding Willingness to Serve* Uncertain Weak Fair Good Very Good Outstanding Willingness to Learn* Uncertain Weak Fair Good Very Good Outstanding Interpersonal Relationships* Uncertain Weak Fair Good Very Good Outstanding Reliability* Uncertain Weak Fair Good Very Good Outstanding Ability to Work with Others* Uncertain Weak Fair Good Very Good Outstanding Communication Skills* Uncertain Weak Fair Good Very Good Outstanding Leadership Skills* Uncertain Weak Fair Good Very Good Outstanding Physical Health* Uncertain Weak Fair Good Very Good Outstanding Comments on any of the above:Would you have the applicant on your staff?* Yes No Why?*Why not?*Does your congregation intend to financially support the applicant?* Yes No Comment:*Your recommendation of the applicant for Succat Hallel’s internship program in Jerusalem:* Highly Recommend Recommend Recommend with reservations Do not recommend Please explain your concerns here:*Thank you for taking the time to complete this form.
