800 Mickelson Drive
Rapid City, SD 57703-4018
605-718-2400 Fax: 605-394-2204
Toll Free: 1-800-544-8765
Student’s Name: ______________________________________ Student ID#:___________________
(Not Social Security #)
I request ___________________________________________ to serve as a reference for me. The
purpose(s) of the reference(s) are (check all that apply)
Application for Employment
All forms of scholarship or honorary award
Admission to another educational institution
Internship corresponding with a Western Dakota Tech Internship Course
I authorize the above-named person to provide an oral or written evaluation of any aspects of my academic
performance, including classroom and/or lab performance, attendance, and attitude, as well as job-related
criteria such as team work, productivity, and ability to work independently, or on my education records at
Western Dakota Tech, and to release information from my education records, including grades, GPA, class
rank, disciplinary actions, any information pertaining to my education at other institutions I have previously
attended which is part of my education records at WDT, and any other personally identifiable information
whether or not contained in my education records to: (must be specific, can’t use “Potential Employer”)
Read and initial each statement below. I understand:
_____ I must contact the WDT Registrar’s Office at 605-718-2568 to add or remove the name(s) of
prospective employers, organizations, or educational institutions. When calling, I must provide the
following password in order make changes: __________________________
_____ I understand that under the Family Education Rights and Privacy Act, 20 USC 1232g: (1) I have the
right not to consent to the release of my educational records; and (2) I have the right to receive a copy of
any written reference upon request.
_____ This reference authorization consent shall remain in effect until revoked by me, in writing, and
delivered to Western Dakota Tech Registrar’s Office, but any such revocation shall not affect disclosures
made by staff of Western Dakota Tech who was authorized prior to the receipt of revocation.
_____ I release Western Dakota Tech, its current or former board members, officers, directors, agents,
employees, and the person providing the above described reference or evaluation from all claims and
liability for damages that may result from their compliance with this request.
Student’s Signature: ________________________________________________ Date: ______________
Please submit completed form to the Registrar’s Office or email completed form to Registrar@wdt.edu.
Received by: ________________________ Entered by: ________________________
Initials Date Initials Date
Original: Registrar’s Office Email of Completed Form: WDT Personnel Named Above