Penn State Office of the University Registrar

Request for Letter of Recommendation

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

This form may be used by a student to authorize release of non-directory information from his/her education record for purposes of a letter of recommendation, application to an educational institution, etc. For each request, this form should be completed and presented to the individual making the recommendation.

Authorization:

I hereby authorize:

(Name of Professor or Other University Official or Organization)

To: write a letter of recommendation

To: complete evaluation form (attached)

To: other (specify):

Send To:

Name, Employer, or Educational Institution:

Street 1:

Street 2:

City/State/Zip:

Evaluation Requirements:

Recipient requires the evaluation by:

For the purpose of: employment

For the purpose of: admission to an educational institution

For the purpose of: application for scholarship or honorary award

For the purpose of: other (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.

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

Student Name:

PSU ID:

Please review your entries on this form. If all of the information is entered correctly, please print (using "Print Form" button at bottom), sign and present it to the individual making the recommendation.

Student Signature: _____________________________________ Date: ___________________

Office Use Only

Is a disciplinary review required? Yes No

Revised 11/18/09