2013-10-02
Reference Request and Student Authorization
Student Name (please print):
I request ________________________________ to serve as a reference for me. The purposes of the reference are
(check all that apply):
Application for employment
All forms of scholarship or honorary award
Admission to another education institution
The reference may be given in the following forms (check one or both):
I authorize the above person to release information and provide an evaluation about any and all aspects of my academic
performance at Inver Hills Community College to the following (check all that apply):
All prospective employers
Specific employers (list on reverse)
All educational institutions to which I seek admission
Specific educational institutions (list on reverse)
All organizations considering me for an award or
scholarship
Specific organizations (list on reverse)
This authorization to provide references is valid for one (1) year from the date of my signature below, unless I specify an
earlier ending date as follows: _____________________
NOTE: Under the Family Educational and Privacy Rights Act, 20 U.S.C. 1232(g), you may, but are not required to waive
your right of access to confidential references given for any of the purposes listed on this form above. If you waive your
right of access, the waiver remains valid indefinitely. Check the appropriate space below:
I waive my right of access to references about me.
I do not waive my right of access to references about me.
Please direct questions about this form to the Inver Hills Enrollment Center (College Center, 2
nd
Floor): 651-450-3503 or
enrollment@inverhills.edu.
IHCC faculty/staff process only:
Step one: Make copy of form for personal records.
Step two: Forward to Enrollment Center for storage.
