PERSONAL REFERENCE STATEMENT

The Texas Board of Professional Geoscientists requires, as part of the licensing process, references to satisfy the Board as to the character, reputation, responsibility, integrity and competence of the applicant.

The applicant shall send a complete PersonalReference Statement formto each reference provider.

SECTION I. Applicant Information

SECTION II.

THE REMAINDER OF THIS FORM TO BE COMPLETED BY RESPONDENT

SECTION II. Reference Provider Information

The above named applicant has applied for licensing as a geoscientist in Texas under provisions of TAC, Title 22, Examining Boards, Part 39, Chapter 851. This form has been supplied to you by the applicant.

REFERENCE PROVIDER’S NAME: ______

ADDRESS:______

PHONE NUMBER:______

Instructions:

(1) Please complete Section III and add any comments or concerns.

(2) Place the completed Reference Statement Formin an envelope; and

(3) After sealing the envelope, the reference's signature shall be placed across the sealed flap of the envelope and covered with transparent tape. The reference shall return the sealed envelope to the applicant.

Applicant’s name: ______

SECTION III. Reference Statement

Your candid appraisal of the applicant’s personal character is appreciated. Please note that reference statements are confidential and not subject to release to neither the applicant nor the Texas Public Information Act.

Please answer the following questions:

  1. How long have you known the applicant?

Personally: ______

Professionally: ______

EmployerSupervisorCo-worker Other, pleasespecify ______

  1. Please indicate your appraisal of the applicant in the following categories:

Excellent Good Poor Unknown

a. Personal honesty

b. Personal integrity

c. Personal ethics

  1. Please include additional information and comments which would amplify or clarify the itemsabove and thus assist the Board in evaluating the applicant’s personal character. Attach additional pages as needed.

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Reference Provider’s SignatureDate

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Reference Provider’s Name (Printed)

Austin Headquarters: Wm. P. Hobby, Jr. Bldg. • 333 Guadalupe, Tower 1, Ste 530 • Austin, Texas 78701

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