Request for Letter of Recommendation

Please fill out this online form, print, sign, and present to the individual making the recommendation.

Please fill out this online form, print, sign and present to the individual making the recommendation.

Authorization

I hereby authorize:

Please enter name of person/organization you authorize to submit a recommendation.

Name of Professor or Other University Official or Organization

To write a letter of recommendation

To complete evaluation form (attached)

To other (specify)

If Other is checked, please specify:

Send To

Name, Employer, or Educational Institution

Please enter the name of the person or place to send recommendation.

Street Address 1

Please enter street address.

Street Address 2

City

Please enter city.

State

Zip Code

Please enter zip code.

Evaluation Requirements

Recipient requires the evaluation by:

Please enter name of person/organization you authorize to submit a recommendation.

For the purpose of:

Employment

Admission to an educational institution

Application for scholarship or honorary award

Other (specify)

If Other is checked, please specify:

I consent to the release of any information from my education record (e.g. grades, GPA) that is deemed appropriate for purposes of the recommendation or evaluation.

Waiver to View Recommendation

Further, I hereby waive my right to see the recommendation at any time in the future.

Further, I hereby do not waive my right to see the recommendation at any time in the future.

Student Identification

Student Name

Please enter your name.

PSU ID 9-digit Penn State ID number

Please enter your PSU ID.

Please review your entries on this form. If all information is entered correctly, please print, sign, and present it to the individual making the recommendation.

Student Signature

Student Signature: _________________________________________________

Date: ____________________________

Student Signature: _______________________________________ Date: __________________________

Office Use Only

Is a disciplinary review required?

Yes

Last Revised: 11/18/09

Office of the University Registrar
112 Shields Building
University Park PA 16802

814-865-6357
registrar@psu.edu