Recommendation Letter Request Form


Medical Careers Advisory Committee
Recommendation for: (name)________________________
School of Science
Application Cycle: (intended start at med school): ___________
The College of New Jersey
Program Type: MD
DO Other: __________
Date of Request:______________________
Recommendation Letter Request Form
To Be Completed by the Student:
“In accordance with FERPA, I authorize my evaluator and the Medical Careers Advisory Committee
(MCAC) to write and finalize a recommendation letter on my behalf which may disclose the following
educational records: courses, grades, gpa, class rank, written evaluations, honors and awards, and
disciplinary action(s). I have requested that this letter be included in my application to med school.
Furthermore, I waive my right to see the contents of the letter written in response to this request.”
Cell Phone
Home Phone
Email Address
To Be Completed by the Evaluator:
This student is requesting that you write a letter of recommendation on their behalf for admittance into
graduate level study at a medical or health-related professional school. Please complete the attached
assessment, and then write your candid evaluation of this student in a separate document, printed on
letterhead and signed. Where possible, cite specific examples of demonstrated academic ability and
personal traits (please see the back of this sheet for more specific characteristics that can be addressed).
Would this student make both a good professional student and practitioner?
I would recommend this student: _____ with enthusiasm
_____ with confidence
_____ with reservation
_____ I do not recommend
Your Signature: _______________________________
Date: _____________
Your Name: ______________________________ Title: _____________________________________
Address: __________________________________________________________________________
Email Address (if we need to contact you): _______________________________________________
I give permission for the MCAC to excerpt all or part of my written comments. ____________ (initial)
Then send both pages of this form (this sheet and chart) with your letter of recommendation to:
Dr. Marcia O’Connell, Chairperson, Medical Careers Advisory Committee
Dept of Biology, The College of New Jersey, PO Box 7718, Ewing, New Jersey 08628-0718
Please print your letter on appropriate letterhead, and be sure to sign it. (If the med school needs a
copy of the actual letter of rec, they will not accept one without a signature or letterhead.) Additionally,
please send an electronic copy of the letter to Your comments will most likely be
incorporated as written (cut and pasted) into a composite letter written on behalf of the student and
forwarded to the appropriate professional schools. The attached form will NOT be sent to professional
schools. On behalf of the student and the Medical Careers Advisory Committee, we thank you for your
taking the time to assist us in this very important process.


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