LoR request

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					                                      Request For Letter Of Recommendation1

Name:                                                               e-mail:

1) What courses have you taken from me?

                                        Course                                               Term/Yr taken
Organic Chem I Lecture
Organic Chem II Lecture
O-Chem Lab I
Intro to Research

2) Specific title, location & deadline for the program(s)/schools/awards to which you are applying (e.g. “Grad
school in Dept of Medicinal Chemistry, U of Michigan” or “REU program in Materials Science, U of Oklahoma”)
(please list them all)
     Title of program                                  Location                                  Deadline

3) Why are you applying for this program?

4) What do you believe are some of your personal characteristics that make you well-suited for this program?

5) Supply any other information that you believe might be relevant to your application (pertinent experience, special
interests, etc.).

                                                                                                        OVER 

1   Only one form need be filled out per year.

September 16, 2012
Request for a Letter of Recommendation, p. 2

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.

By signing this form, you agree to allow me to release information about your academic record (grade, class rank,
percentage of total points you earned, etc.) and provide an evaluation about any and all aspects of your academic
performance at the University of Minnesota Morris to the following (check all that apply)

     All prospective employers                            OR        Specific employers (list on reverse)
     All educational institutions to which I seek
                                                          OR        Specific educational institutions (list on reverse)
     All organizations considering me for an award
                                                          OR        Specific organizations (list on reverse)
     or scholarship

This authorization to provide references is valid for one year from the date of your signature below.

 I waive my right of access.
Signature:                                                                         Date:

September 16, 2012

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