Letter of Recommendation Form


Indiana University School of Dentistry
Office of Graduate Education
1121 W Michigan Street, Room 104A
Indianapolis, IN  46202     USA

Applicant's Information

Recommendations should be requested from instructors who are able to comment on your qualifications for graduate dental study.  They should not be requested from a non-academic person unless you have extensive work experience with that individual and/or you have been away from academic institutions for some time.  Deliver this form directly to the recommender, along with a stamped envelope addressed to the Indiana University School of Dentistry Office of Graduate Education.

Please print:

Name______________________________________________________________
Last or Family Name/Surname                   First                       Middle

Date of Birth ________________________________________________________

E-mail address _____________________________________________________

Major Field of Study _________________________________________________

Applicant's Waive of Right to Access

The Family Educational Rights and Privacy Act of 1974, as amended (P.L. 93-380), allows a candidate for admission to waive his or her right to confidential letters or statements written on his behalf if the recommendation is used solely for the purpose of admission and if the candidate, upon request, is notified of the names of all persons making such recommendations on his or her behalf.  The University does not require that you make such a waiver as a condition of admission.  However, under this legislation you have the option of signing such a waver as follows:

I hereby waive my right to access to this recommendation and any appropriate attachments which have been written by __________________________________________________________________________ (insert name of recommender) on behalf of my application to Indiana University School of Dentistry.  This waiver is effective insofar as the recommendation is used solely for the purpose of admission.

Printed Name ___________________________________________  Date _________

Signature _____________________________________________________________

To the Recommender:

Please write a detailed and candid letter to assist us in judging this applicant.  Especially helpful would be information concerning the applicant's academic capabilities based upon past performance.  The letter should be written and signed on academic or business letterhead stationery.

Please staple this form to your letter of recommendation.  Both should be placed in the stamped envelope provided by the applicant, sealed, and sent directly to the IUSD Office of Graduate Education.