ࡱ> 463#` bjbj\.\. *>D>D ${$1hx  5FFF FFFF 2iE:FfK0{F<FF F  < {8 8  S A M P L E REFERENCE REQUEST AND STUDENT AUTHORIZATION Student Name (Please print): __________________________________________________ I request _______________________ to serve as a reference for me. The purpose(s) of the reference are: (check all applicable spaces) ________application for employment ________all forms of scholarship or honorary award ________admission to another education institution The reference may be given in the following form(s): (check one or both spaces) ________written ________oral I authorize the above person to release information and provide an evaluation about any and all aspects of my academic performance at the [Name of College or University] the following: (check all applicable spaces) 1. ________ all prospective employers specific employers (list on OR ________ reverse side)  all educational institutions to 2. ________ which I seek admission specific educational institutions OR ________ (list on reverse side) all organizations considering me 3. ________ for an award or scholarship specific organizations (list on OR ________ reverse side) This authorization to provide references is valid for one (1) year from the date of my signature below, unless I specify an earlier ending date as follows: Ending date:___________________________ NOTE: Under the Family Educational and Privacy Rights Act, 20 U.S.C. 1232(g), you may, but are not required to waive your right of access to confidential references given for any of the purposes listed on this form above. If you waive your right of access, the waiver remains valid indefinitely. Check the appropriate space below: ________ I waive my right of access to references about me. ________ I do not waive my right of access to references about me. _____________________________________ __________________________________ Name Date 9:  hZ65CJ hZ6CJ hZ65 hZ65CJ  9:  5 6 i j      F a $If$a$a b k l m " mEkdQ$$Ifl0&DD4 la$IfEkd$$Ifl0&DD4 la" # $ % & mEkd$$Ifl0&DD4 la$IfEkd$$Ifl0&DD4 la v w *+no$a$EkdD$$Ifl0&DD4 la(/ =!"#$% O$$If!vh5D5D#vD:V l5D4O$$If!vh5D5D#vD:V l5D4O$$If!vh5D5D#vD:V l5D4O$$If!vh5D5D#vD:V l5D4O$$If!vh5D5D#vD:V l5D48@8 Normal_HmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List  9:56ijFabklm"#$%&vw*+no00000000000000000000000 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0000000000000 9:56ijFabklm"#$%&vw*+noh0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h0h00 h0h0h0h0!h0h0h0h0h0Nh0h0h0h0h0h0h0h0h0h0h0h0h0a "   ;>Zb3333Z6v abklm"#$%& 3@Pu`@UnknownG: Times New Roman5Symbol3& : Arial"hFF**!242HX)?v 2 S A M P L E System OfficeDorothy Zenner Oh+'0   @ L Xdlt| S A M P L ESystem Office Normal.dotDorothy Zenner 2Microsoft Office Word@G@b%@b%*՜.+,0 hp  MnSCU  S A M P L E Title  !"$%&'()*,-./0125Root Entry FmE7Data 1TableWordDocument*SummaryInformation(#DocumentSummaryInformation8+CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q