This part is to be completed by the applicant prior to giving the form to the evaluator.
Last Name (legal name)
Last 4 digits of Social Security Number
Home Street Address
Intended Graduate Program of Study:
Waiver Selection and Signature:
I waive the right provided by the Family Education Rights and Privacy Act of 1974 to view this letter of recommendation.
I do not wish to waive this right. I wish to retain the right to view this letter of recommendation.
Applicant’s Signature: ______________________________________________________________________Date: ________________________
The person whose name appears above is applying to a graduate program at Fitchburg State University.
We would appreciate your candid appraisal of this applicant relative to admission.
As required by the Family Education Rights and Privacy Act of 1974, a student may elect to waive the
privilege of viewing this recommendation form. If the student has not waived this right in the section
above, you should consider this form to be non-confidential.
Name of Person Making the Evaluation
Relationship to Applicant (check one):
1. How long and in what capacity have you known this applicant?