Reference Release Form
New Page 1
PERMISSION TO RELEASE
REFERENCE INFORMATION
I, (print
name)____________________________________________________, hereby grant permission to ________________________________________________ to serve as a reference and to release information to employers, educational institutions, and foundations for the purpose of assisting me in obtaining employment, admission to graduate or professional school, fellowships, and/or scholarships. I further consent to the disclosure of information regarding my academic and extracurricular
performance, specifically including grades, attendance, demonstrated skills and objectives.
Signature:
___________________________________________
Date: ______________
Contact: Director, Career Center
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| http://sdmines.sdsmt.edu/referenceform |
Last Modified: 03/23/2007 |
