Request for Letter of Recommendation
Student Information
Name _____________________________________________________
Address _____________________________________________________
U-Number U_______________________
Request and Recipient Information
I give Professor/Instructor _______________________________________ permission
to write a letter of recommendation to:
Name _____________________________________________________
Street Address 1 _____________________________________________________
Street Address 2 _____________________________________________________
City/State/Zip _____________________________________________________
Release of Student Education Record Information
YES. The professor/instructor may include the following information in the letter:
______________________________________________________________
______________________________________________________________.
NO. The professor/instructor may NOT include the titles, grades, and cumulative
GPA of the courses I took from him/her.
Student’s Waiver of Right to Review
YES. I waive my right to review a copy of the letter at any time the future.
NO. I do NOT waive my right to review a copy of the letter at any time in the future.
Note:
If your letter of reference is/was submitted through a third-party online reference
system, it will not be available for your review.
_____________________________________________ _____________________
Student Signature Date
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