ALABAMA BOARD OF LICENSURE
FOR PROFESSIONAL GEOLOGISTS
610 S. McDonough Street
Montgomery, AL 36104
FORM FOR PERSONAL REFERENCE
NAME AND ADDRESS __________________________________________
OF APPLICANT __________________________________________
I WAIVE MY RIGHT TO INSPECT THE CONTENTS OF THIS DOCUMENT
SIGNATURE_______________________________ DATE ______________
TO BE COMPLETED BY THE APPLICANT
TO BE COMPLETED BY RESPONDENT
The above named applicant has applied for licensing as a geologist in Alabama under the
provisions of Title 34, Chapter 31 of the Alabama Code, 1975. The Alabama Board of Licensure for
Professional Geologists requires as part of the licensing process, personal references are required to
satisfy the Board as to the character, reputation, responsibility, integrity and competence of the applicant.
These references must be submitted by a personal acquaintance or professional colleague who has
known the applicant for at least 5 years immediately prior to submittal of this application on for licensure
on the reference forms provided. PLEASE TYPE OR PRINT NEATLY.
This form will be supplied to you by the applicant. However, you are requested to mail the
completed form directly to the Board. Information will be treated by the Board as strictly confidential.
Your candid appraisal of the applicant's personal character is appreciated.
1. Your name:
2. Your address:
Telephone No. __________________________________
3. How long have you known the applicant:
a. Personally ?
b. Professionally ? __________
This form maybe reproduced as required.
What has been your personal relationship with the applicant?
[ ] Employer
[ ] Supervisor
[ ] Co-worker
[ ] Other
[ ] Friend