To be filled out by the Pastor or Youth Pastor of UGM participant:

Name of Applicant:

Your Name:   Church Name:

Street Address:

City:   State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Phone #:   Fax #:

Email Address:

How long have you known the applicant?

How well do you know him/her? Very Well Well Casually

Would you describe the applicant as having a servant's heart? Please elaborate:

In your opinion, is the applicant able to deal with adversity in a positive and Christ-like way?

Which of the following best describes the applicant?

E=Excellent    AA=Above Average    A=Average    P=Poor    U=Unknown

Adaptability: E AA A P U

Servanthood: E AA A P U

Dependability: E AA A P U

Spiritual Life: E AA A P U

Maturity: E AA A P U

Response to Authority: E AA A P U

Spiritual Influence on Peers: E AA A P U

Leadership Ability: E AA A P U

O=Often    S=Sometimes    R=Rarely    N=Never

Procrastinates: O S R N

Critical: O S R N

Irritable: O S R N

Inclined to Crushes: O S R N

Depressed: O S R N

Argumentative: O S R N

Domineering: O S R N

Rebellious: O S R N

To your knowledge:

Is the applicant active in his/her church? Yes No
In what activities has the applicant been active, either in your church or other Christian ministry?

Is the applicant visibly growing in his/her faith? Yes No

Has the applicant had a salvation experience? Yes No

Has the applicant's interest in missions been influenced by a desire to escape a difficult situation (family problems, financial struggles, troubled romance)? Yes No

Has the applicant used tobacco, alcohol, or illegal drugs in the last year? Yes No

Are you aware of any mental or emotional illness or instability in the applicant? Yes No

Have you ever had reason to question the applicant's morals? Yes No

Do you have any reason to lack confidence in the applicant? Yes No

Please use the following space to comment on any of the above questions...

Based on the above information, the applicant is:
Strongly Recommended
Recommended
Recommended with Reservation
Not Recommended

Help us by listing a few pastors you would recommend us to contact about our outreach opportunities for their youth and young adults. Please give us their contact information (name, address, phone, fax, & e-mail).

Your recommendation is held in strict confidence. You may receive a phone call from a UGM staffperson to verify that you filled out this information. Thank you for your recommendation.