Use Typewriter or black ink.
Waiver:
I waive the right to review reference responses to this form.
Minister's Signature
_____________________________________ Dated:______________________
To the Reference: The person listed below has given your name as
a reference. Please complete this form and return it to Dayspring Ministries International. Neatness, clarity and dark copy
which will reproduce well are essential. If the waiver has been signed the information you put on the form will be kept in
confidence, but will be seen by the Board of Directors of DMI. Thank you for your assistance.
Please mail this form to: Dayspring Ministries International
Dr. Gary Barkman, Archbishop
P.O. Box 863, Brookhaven, MS 39602
Minister's Name ______________________________________________
Address ___________________________________________________________
Address 2 _________________________________________________________
Phone #'s _____________________________ E-Mail_______________________
_
Reference Name ____________________________________________________
Address __________________________________________________________
Phone #'s _____________________________ E-Mail_______________________
How Long have you known this person:_______________________
Relationship: ___ Lay member of present congregation ___
Lay member of previous congregation ___ Clergy Colleague
___ Counselor / Therapist Colleague ___ Fellowship / Denominational
Leader /
Staff ___ Family Friend
Other ______________________________________________________________
PERSONAL CHARACTERISTICS
Please place the appropriate number in the blank following the personal
characteristic:
1 Exemplary 2 Many Times 3 Sometimes 4 Do Not Know
1. Follows through with responsibilities ___
2. Protects confidentially ___
3. Handles pressure well ___
4. Manages time wisely ___
5. Appropriate personal appearance ___
6. Likes people ___
7. Handles conflict well ___
8. Portrays Christian maturity ___
9. Takes criticism well ___
10. Takes praise graciously ___
11. Seeks help from others when needed ___
12. Takes time for study ___
13. Is creative/imaginative ___
14. Has a positive attitude ___
15. Is flexible/adaptable ___
16. Is a good listener ___
This person uses the following leadership style (Rank 1, 2, 3)
___ Takes primary initiative and responsibility
___ Allows laity or to take primary responsibility
___ Shares responsibility with laity
For what type of situation do you feel this person best suited? _________________
___________________________________________________________________
Are there counseling or ministerial situations for which it would
be unwise to consider him/her?
_______________________________________________________________
__________________________________________________________________
Does this person maintain confidentiality; being compassionate
and sensitive to others needs; helping persons develop emotional maturity and security?
__________________________________________________________________
Does this person help persons develop their spiritual life;
encouraging persons to relate their faith to their daily lives? _________________________________
Does this person make calls on persons in hospitals; ministering
to persons in crisis situations? ____________________________________________________
Are there other comments which would assist Dayspring Ministries
International in making a decision to certify or not certify this person? (Please limit your comments to this and one
other page.)