MAROUETTE UNIVERSITY
STUDENT REFERENCE REQUEST FORM
Student name (please print):_____________________________________________________
Marquette Student ID Number: __________________________________________________
I, the above-named student, hereby request that
or ………………………………………………. (hereinafter "Employee(s)") serve as a
reference for me. This reference is for the following purpose(s): (check all that are applicable)
application/reference for employment
all forms of scholarship or honorary award
admission to an educational institution/program
The reference may be given in the following form(s): (check one or both spaces)
written oral
I authorize Employee(s) to release any and all information from my education records, as defined in the
Family Educational Rights and Privacy Act (FERPA) and to provide an evaluation relating to my
education at Marquette University (including but not limited to grades, coursework, internship evaluations
and comments by agency supervisors) to the following: (check one)
- all prospective employers, educational institutions to which I seek admission and all
organizations considering me for an award or scholarship OR
- only those specific employers, educational institutions and/or organizations listed on the
reverse side of this form
I further authorize the release of information relating to student teacher evaluations, if applicable:
Yes No Not applicable
I understand and agree that this authorization shall remain in effect until revoked by me, in writing,and
delivered to Employee(s), but that any such revocation shall not affect disclosures previously made by
Employee(s) prior to receipt of such written revocation. Further, I hereby agree to indemnify, defend and
hold harmless Employee(s), and Marquette University, for any claim arising out of, or related to, any
reference or information provided pursuant to this authorization.
Signature of Student: _________________________________ Date: ___________________________
List all employers, educational institutions and/or organization to which I authorize the release of
information by Employee (attach additional sheets if necessary):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(Attach'additional'shee ts'if'neces sary)
