Student name (please print):_____________________________________________

I request Prof. Stephen Chilton 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 University of Minnesota to the following: (check all applicable spaces
 

1.	________	all prospective employers	OR	________	specific employers (list on reverse side)
2.	________	all educational institutions to which I 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. Check the appropriate space below:

 

_______________________________________ Signature

_______________________________________ Date