Student Reference/Recommendation Request

Student Reference/Recommendation Request Release
Student Name*

First NameMiddle NameLast Name
Student Email*
email@example.com
Middlesex College ID Number*
Major*
Name of Faculty/Staff Reference or Recommender*

First NameLast Name
Email of Faculty/Staff Reference or Recommender*
example@example.com
This reference/recommendation is for the following purpose(s):*

Application/Reference for EmploymentAdmission to Another Educational InstitutionAll Forms of Scholarships or Honorary AwardsOther
The reference may be given in the following form(s):*

WrittenOral/Verbal
Why are you applying for this university/program/job?
Please provide additional information to facilitate preparation of your reference/recommendation.

I authorize release of any and all information from my education records to the following:*

ALL prospective employers/educational institutions to which I seek admission and all organizations considering me for an award/scholarship.ONLY the specific employer(s), educational institutions(s) or organization(s) provided.
By requesting this reference/recommendation, I agree that the stated Faculty/Staff has my permission to include in the reference letter my GPA, course grades, academic performance, and any other information the individual believes is pertinent to meet the purpose of this letter.
I waive my right to inspect and review a copy of this letter of reference at any time in the future*

YesNo
Note to students: if you do not waive your right to review, that fact may be noted in the reference letter.
Student Signature*
Reference Signature
Should be Empty:

Student Reference/Recommendation Request Release