Reference Form for Graduate Application

reference form for Graduate application under the family educational Rights and privacy act of 1974, a student enrolled at virginia tech has access to his or her academic records. We comply with this law, while still allowing the option of waiving the right to access this specific document. Waiving this right does not preclude you from access to the rest of your academic records. You may sign below to waive your right to have access to this document. Your choice will not affect the consideration of your application to virginia tech.

appliCant to Complete

laSt/familY name

fiRSt/Given name

middle name

Suffix

Student id number: if known

desired program

degree desired
□ Doctoral □ EDucation SpEcialiSt □ MaStErS □ GraDuatE cErtificatE year □ non-DEGrEE □ coMMonwEalth caMpuS

date of Birth: month/day/year e-mail address:
@vt.edu account, preferred

first term of enrollment desired
□ fall □ SprinG □ SuMMEr i □ SuMMEr ii

daytime phone: local address
□ home □ office □ Mobile

campus
□ BlackSBurG □ haMpton roaDS □ national capital rEGion □ richMonD □ roanokE □ SouthwESt VirGinia □ Virtual

city

state

zip

country

appliCant SiGnatuRe

date

Applicant: Please provide the mailing address of the department to which you have applied to assist your reference.

reference: please return this completed form to the following department:

reference to complete name: address

RefeRenCe to Complete

title: School/company: city state zip country

daytime phone:

e-mail address:

if available, provide the applicant’s relative standing in your department. how would you rate this applicant in overall ability and promise in comparison with others at the same level of training? top 1% to 2% 3% to 5% 6% to 10% 11% to 25% 26% to 50% beloW 50%

Give your opinion of the applicant’s academic and research abilities, providing examples where appropriate. please indicate how long you have known the applicant, and in what