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):

Other
The reference may be given in the following form(s):
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:
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
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