PREPROFESSIONAL EVALUATION REQUEST FORM
In order to facilitate the
collection of evaluations written on your behalf, please fill in the top half
of this evaluation request form.
YOUR
NAME________________________ UNIVERSITY
ID # 899-
STREET
ADDRESS___________________________
MAJOR _____________________
CITY,
STATE ZIP CODE .
E-mail
address
Telephone
number where you can be reached
PROGRAM
TO WHICH YOU ARE APPLYING__________________
Applicants to medical school: AMCAS
# _____________ AACOMAS # _____________
The
Family Educational Rights and Privacy Act of 1974 and its amendments guarantee
students access to their educational records.
Students, however, are entitled to waive their right of access
concerning recommendations. The
following signed statement is the applicant's wish regarding this
recommendation. (Please check one box.)
o I waive my right to inspect the contents of this
recommendation.
o I do not waive my right to inspect the contents of
this recommendation.
Signature
Date
Please
write down the names (and addresses if they are off-campus) of people to whom
you want evaluations sent. (Do not fill
in the "Date sent" or "date received" blanks.)
|
Name,
e-mail address (& physical address if addressee is either off-campus or
does not have e-mail) |
Date Sent |
Date Received |
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Please
indicate the names and addresses of programs to which you plan on
applying. (Do not fill in the “Date
sent” or “Date acknowledged blanks.” Add
more sheets if necessary.)
|
Name
of program, Name of contact person, physical address of program. |
Date Sent |
If applying to medical school, have you received a
secondary application? |
Date ac-knowledged |
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