7/24/2019 Reference Form 2

1/4

Confdential Reerence Formor CISV Leadership / Sta

Position

Confdential Reerence Form or CISV Leadership / Sta Position(The only ofcial text or this orm is this English edition.)

SECTION ! "PPLIC"NT#S INFOR$"TION (To be flled in by Applicant)

%i&en Name

S'rname

N'm(er ) Street

To*n / Cit+

"rea / State / Pro&ince

Co'ntr+Postcode / ,ip

code

Co'ntr+ Code "rea Code Local N'm(er

Tel

Fa-

$o(ile N'm(er

E mail

The "pplicant is see.in appointment as 0tic. correct position (elo*12

Camp Director International Sta Home Sta

eader !"nior Sta#eader !"nior Co"nsellor

In the ollo*in CISV proramme2

To (e held in ( indicate host CIS$ co"ntry )%

"pplicant has pro&ided CISV Proramme and Leadership 3escription toReeree(Indicate &es or 'o)

The Reeree is as.ed to please send the completed to 0please indicate contact name and

details needed or the person *ho m'st recei&e the completed reerence orm1!

SECTION 4! FOR REFEREE TO CO$PLETE

3ear Reeree5 the person named aoe has applied or a ol"nteer leadership position in a CIS$programme. He # she *ill *or+ *ith international yo"th rom seeral nations and c"lt"ral traditions.D"ring the CIS$ programme, the applicant *ill sere as a role model in o"r peace ed"cation actiitiesand *or+ to create an enironment *here cross-c"lt"ral riendships and international cooperation arepossile. The applicant *ill e in a position o tr"st as riend, ed"cator and g"ardian o the yo"thparticipating in the CIS$ programme noted elo*. (CIS$ programme and position description descriingthe d"ties relatie to this application hae een attached y the applicant.). lease complete the ormin English or international positions or, it can e in the lang"age o /pplicant or a position in thatperson0s o*n co"ntry. CIS$ programme ofcials, the parents and the participating yo"th than+ yo" oryo"r assistance in selecting appropriate personnel or CIS$0s international peace ed"cationprogrammes.6o'r response *ill (e treated as pri&ate and confdential and destro+ed aspro&ided (+ la*!

CISV International Ltd

Ofcial Form

($alid rom 1223) age 4 o 5

7/24/2019 Reference Form 2

2/4

/s a g"ide or the 6eeree, CIS$ does not consider persons exhiiting the ollo*ing ehaio"r to e

appropriate or a position o leadership% alcohol # dr"g a"se, serio"s criminal conictions, dishonesty,

emotional or ehaio"ral dist"rance, pre7"dice, sex"al a"se, iolence, lac+ o sel control,

intolerance, or the inaility to appropriately deal *ith stress.

Reeree is a mem(er o CISV(Indicate&es or 'o)

Reeree has .no*n the "pplicant or &ears

Reeree sees / comm'nicates *ith the

"pplicant(tic+ appropriate ox)%8ten Sometimes Seldom

Reeree#s relationship *ith "pplicant(tic+ appropriate ox)9or+ S"perisor Teacher#roessor 6elatie

:amily :riend ersonal :riend St"dent

CIS$ ;emer Co-9or+er 8ther(please speciy)

CISV International Ltd

Ofcial Form

($alid rom 1223) age 1 o 5

7/24/2019 Reference Form 2

3/4

REFEREE#S INFOR$"TION

%i&en Name

S'rname

N'm(er ) Street

To*n / Cit+

"rea / State / Pro&ince

Co'ntr+Postcode / ,ip

code

Co'ntr+ Code "rea Code Local N'm(er

Tel

Fa-

$o(ile N'm(er

E mail

Name o "pplicant2Position applied or2

In m+ opinion5 CISV *o'ld / *o'ld not (stri+e o"t or delete as appropriate) (eneft (+ ha&inthis "pplicant in a position o responsi(ilit+ in its cross7c'lt'ral and international peaceed'cation prorammes or the ollo*in reasons2

Special s.ills or other comments2

3eclaration2

To the est o my +no*ledge, the inormation I hae proided ao"t the /pplicant is tr"e, acc"rate andcomplete. I am not a*are o past#present ehaio"r y the /pplicant that *o"ld dis o 5

7/24/2019 Reference Form 2

4/4

CISV International Ltd

Ofcial Form

($alid rom 1223) age 5 o 5