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									                                 University of Missouri
                             Community Service Referral Form


Student Name:____________________________________________________________

Number of Hours to be Completed:______________ Due Date:____________________

Special Notes/Comments on Service Requirement:_______________________________

_______________________________________________________________________

Referred by: ___________________ Date of Referral:__________ Phone: 573-882-5543


                             To be completed by agency contact


Sponsoring Agency/Department:_____________________________________________

Agency Address:__________________________________________________________

Agency Phone #: _________________________________________________________

Agency Contact Person:____________________________________________________

Total Hours Completed:____________________ Date of Completion:_______________

How would you describe the student’s:

                Above Average                 Average                    Below Average

Attitude         _________                   _________                   ___________

Reliability      _________                   __________                  ___________

General Comments:_______________________________________________________

Signature of Agency Contact:_________________________________ Date:__________


               Note to Agency contact: After signing, immediately return to:
           Donell Young, Sr. Coordinator, Judicial Services, N229 Memorial Union
                       University of Missouri, Columbia, MO 65211
                               Thank you for your assistance.

								
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