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* 1. Name of applicant you are providing this reference for:

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* 2. Your name:

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* 3. Organisation:

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* 4. Job title:

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* 5. Email address:

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* 6. Phone number:

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* 7. What is your relationship to the applicant, how do you know them?

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* 8. How long have you known the applicant for?

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* 9. How does the applicant make an impact through health/care?

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* 10. Would you describe the applicant as 'a leader'? If so why?

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* 11. How do you believe that the applicant would benefit from participating in the One Young World Summit?

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* 12. Do you believe the applicant can benefit from gaining coaching from Johnson & Johnson, if so in what way(s)?

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* 13. The applicant will be required to devote up to 10% of their working hours to the Johnson & Johnson Scholarship Program between July 2018 and January 2019. Are you aware of any circumstances that would prevent the applicant from meeting this time commitment?

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* 14. If you do not believe the applicant has sufficient time to fully participate in the Program, please explain why?

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* 15. Declaration: I confirm that the information I have provided is true and accurate:

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* 16. I give permission for One Young World to contact me via the email address or telephone number I have provided if they have any questions regarding this reference:

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