OFFICE OF CAREER COUNSELING AND PLACEMENT
                                                                                             Bethany College
                                                                  Morlan Hall - Room 008, Bethany, WV 26032
                                                                                       Phone: (304) 829-7150
                                                                                         Fax: (304) 829-7194

In an effort to secure employment or graduate/professional school admission, I hereby request and
authorize the Office of Career and Professional Development at Bethany College to receive from persons
or institutions, selected by me, letters of recommendation written by those persons or institutions. In
accordance with Section 438 of the Family Educational Rights and Privacy Act of 1974, (Public Law 93-380),
commonly called the “Buckley Amendment.” I realize that these letters of recommendation will be
maintained on a confidential basis, and not disclosed, except to those employers or institutions who desire
the information contained therein for purposes of reviewing an application for employment or
graduate/professional school admission. However, I too, have the right to access to these letters of
recommendation, unless I choose to waive my right to access to any or all letters of recommendation. I will
determine my right of access and/or waiver of access to the letters of recommendation on the forms used
by me for the purpose of gathering such letters.

Authorization to Release Placement Records

(Please Select One Option)

I authorize representatives of the Office of Career and Professional Development to collect and maintain a
file of credentials for the purpose of assisting me in my search for employment and or admittance to a
graduate or professional program. I further authorize the Office of Career and Professional Development to
send my credentials to prospective employers or graduate institutions under the following guidelines:

__________    As requested by me

__________    As requested by me or at the request of a prospective employer (s) or graduate institution (s)

The Office of Career and Professional Development shall in no way be liable for any consequences resulting
from such disclosure.

Candidate’s Name                                                   Date

Candidate’s Signature                                              United States Social Security #

For Office Use Only
Name of Reference Giver        Non-Confidential    Confidential     Date Received by Career Office

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