Reference Form For Undergraduate Degree Programs printable pdf download

Reference Form For Undergraduate Degree Programs

Reference Form for Undergraduate Degree Programs

To be completed by applicant:

Name of applicant: ____________________________________________________ Other name(s) used: __________________________________________

Address: _________________________________________________________________________________________________________________________

City:_____________________________________State:________ Zip:________________ Phone: (_________) _______________________

 Adult Cardiac Sonography & Vascular Sonography – dual major

 Healthcare Studies

Program applying for:

 Biomedical Sciences

 Health Sciences

 Diagnostic Medical Sonography

 Nursing (BSN)

RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to inspect their files upon request. In order to inform the

person you have requested to complete this reference form whether the form will be held in confidence or if the letter will be open to your inspection,

please check one of the following statements. Waiving your rights to see this form is not a requirement for admissions.

 I do hereby waive my right to access this reference form.

 I do not hereby waive my rights to access this form.

Applicant Signature: ___________________________________________ Date: _______________________

Please return by: ________________________

To be completed by reference:

Reference name: _____________________________________________________________________ Date: _______________________________________

(please print)

Relationship to applicant: _________________________________________ How long have you known the applicant: ______________________________

How well do you know the applicant?  Very well

 Somewhat well

 Not well