MERCER UNIVERSITY SCHOOL OF MEDICINE MASTER OF PUBLIC HEALTH

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					                     MERCER UNIVERSITY SCHOOL OF MEDICINE
                       MASTER OF PUBLIC HEALTH PROGRAM
                   PROFESSOR/EMPLOYER/FRIEND REFERENCE FORM
                          (To be attached to the letter of reference)

Applicant’s Name_______________________________________________________
                   Last              First             Middle

TO THE APPLICANT: The right to have access to the accompanying letter is given under the
Family Rights and Privacy Act. Please indicate below whether or not you desire to waive your right of
access to this letter should you be admitted and actually enrolled at Mercer University School of
Medicine Master of Public Health Program. If you do not waive your right, this fact will not affect
your chances of acceptance in any way.

I hereby ( ) waive ( ) do not waive my right to see the accompanying letter if I am admitted and
actually enrolled at Mercer University School of Medicine Master of Public Health Program. I
understand that I do not have any right of access if not accepted.

________________________________
Applicant’s Signature
=========================================================================
TO THE RESPONDENT: The applicant named above has chosen you to submit a Letter of
Recommendation in support of an application to Mercer University School of Medicine Master of
Public Health Program. As you formulate your thoughts, please keep in mind the mission and the
educational methodology of our program. The mission of the MPH Program is to educate students to
become community responsive health professionals who are trained to meet the health industry needs
of rural and underserved areas.

As you write this letter, please address:
       ♦ How long and in what capacity have you known the applicant;
       ♦ The applicant’s leadership potential, interest, and involvement in community service
          activities, and potential to be a strong, independent learner; and
       ♦ Whether or not this applicant would be a good candidate for the Master of Public Health
          Program at Mercer University.

Please include any additional information that you feel would be helpful in describing this applicant.
Your rating of this applicant relative to peers would be especially helpful.

This form must be signed by you and attached to the letter. Please return to Mercer University, School
of Medicine, Admission Office, 1550 College Street, Macon, GA 31207.

Your Name___________________________________________________________

Title________________________________________________________________

Address _____________________________________________________________

Email _______________________________________________________________