Fillable Printable Student Reference Request/Letter of Recommendation Authorization Form

Student Reference Request/Letter of Recommendation Authorization Form

Michigan State University

Student Reference Request / Letter of Recommendation

Authorization Form

References/Recommendations which are made from the recommender’s personal observation or knowledge do not require

a written release from the student who is the subject of the reference/recommendation. However, if the student wishes the

recommender to include personally identifiable information from the student’s education record (such as grades, GPA,

etc.), the student must provide a signed release.

Student Name ____________________________________________ Student Number _____________________

I request ___________________________________________________ to serve as a reference for me to:

Name: ___________________________________________________________________________________

Organization/School: _______________________________________________________________________

Address: _________________________________________________________________________________

City, State, Zip: ___________________________________________________________________________

Phone Number: ___________________________________________________________________________

The purpose(s) of the reference is/are (check all that apply):

application for employment

all forms of scholarship or honorary awards

admission to another education institution

other (please explain): _________________________________________________________________

_________________________________________________________________

The reference may be given to the recipient in the following form(s) (check one or both options):

written

oral

The following information may be disclosed from my educational records at Michigan State University for the purpose

of the reference: _________________________________________________________________________________

_______________________________________________________________________________________________

I waive / do not waive my right to review a copy of this letter at any time in the future.

___________________________________________________________ _____________________________

Student’s Signature Date