Student Records Reference Letter Request Form printable pdf download

Student Records Reference Letter Request Form

Student Records

Reference Letter Request Form

This form is to be retained by the referee as confirmation of the request for a reference. It should

not be returned to the student or sent to the graduate program to which the student is applying or

to potential employers.

request that

write a

(name of student)

(name of referee)

letter of reference or respond to a reference check on my behalf.

I understand that in order to write the letter of reference,

(name of referee)

will need to comment on grades and personal characteristics relating to my academic

performance and /or employment history.

I agree to this disclosure of my personal information:

Only to the following schools or potential employers

A signature on this form does not give the

University authorization to provide the Referee

with any information regarding the Student's

record. The Student must provide the Referee

with a Program Summary or Transcript if

comments regarding overall performance (e.g.,

GPA or ranking) are to be included in the

reference.

To all requests for references

This consent will be effective for one year past the signature date.

Signature:

Date:

(Student signature)

(If this form is not signed, a reference will not be provided.)

This information is collected under the authority of and in response to the Freedom of Information

and Protection of Privacy Act. It is required to respond to the request. If you have any questions

about the collection or use of this information, contact the Information and Privacy Co-ordinator at

the University Archives, MLT 1218, 220-3602.

March 19, 2001

Student Records Reference Letter Request Form