University of Minnesota Duluth

Student Reference Request Consent Form 

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 and/or employment performance at the University of Minnesota Duluth to the following: (check all applicable spaces)

1. __ all prospective employers

OR __ specific employers (list on reverse side)


2. __ all educational institutions to
which seek admission

OR __ specific educational institutions (list on reverse side)

3. __ all organizations considering me for an award or scholarship
OR __ specific organizations (list on 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.

 

_____________________________________
Student Signature

_____________________________________
Date