Request for Evaluation/Recommendation Letter – Dr. Hanna Broome
A. Student Information
Name _____________________________________ UMMC number: _______________________
This letter is for the following: ____Professional school application ___Job application ___Other
Date (month/year) that you submitted your professional school application, if applicable: ________
B. Individual or Institution to whom letter will be sent:
Name of Individual/Institution _____________________________________________________
Date to send the following information ________________________
(check one) ____ by e-mail OR ____ by mail
Address ___________________________________________________________________
__________________________________________________________________________
C. The only type of information that is to be released under this consent is:
Current grades in current, in-progress courses
Full academic record for completed courses (only after you've completed courses)
Dates of enrollment
Other (please specify) ________________________________________________
D. The information is to be released for the following purpose:
Recommendation letter for application to professional school
Update letter for an application previously submitted to professional school
Letter of reference for employment
Other (please specify) ________________________________________________
E. Waiver and consent
______ I waive my right to examine this evaluation/recommendation letter, and grant consent for the
(initials) School of Graduate Studies to release the aforementioned information.
Student Signature _______________________________________ Date ________________________
FERPA Overview
I understand that any and all personally identifiable information is protected under The Family
Educational Rights and Privacy Act of 1974 (FERPA). Complete information about FERPA can be
accessed on the Enrollment Management website. I agree to waive my rights under FERPA and allow
the individual/institution named above access to my specified academic records, provided by the School
of Graduate Studies in the Health Sciences at University of Mississippi Medical Center.
Check this box to indicate that you understand the FERPA law and information above, and that
yougive your consent for the specified information to be sent to the individual/institution above.
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