Preparing for Medical School - Page 51

Request Form for a Letter of Recommendation

_________________________ UNIVERSITY

Prehealth Professions Committee

Re:

Request for Preparation of a Letter of Recommendation

Please prepare supporting material on the applicant's behalf for (check one or more):

medical _________, dental _________, osteopathy _________, podiatry _________,

optometry _________, other (specify) __________________

Application for class entering: _____________________

Today's date ______________

Name:______________________________________________ Date of birth: ____/_____/____

(last)

(first)

(middle)

Local address:

________________________________________________________________

(number and street)

(city)

(state)

(zip)

Permanent address: ____________________________________________________________

(number and street)

(city)

(state)

(zip)

Telephone number: _______________________________

(area code)

(number)

Citizenship: U.S. _______________ Other: (specify) _______________

Father's occupation: _____________________ Mother's occupation: ______________________

Credits transferred (if any): ___________, Completed: __________, In progress: ____________

The data below should refer only to the applicant's performance at ________________ University.

Current Grade Point Average: _____________ Science cum (including math): ____________

Major: _________ Major average: _________ Minor: _________ Minor average: _________

Has the applicant's education to date been continuous other than for vacations?

Yes: ________ No: ________

If the answer to the previous question is in the negative, indicate what the applicant has done

while out of attendance or since graduation.

______________________________________________________________________________

Has the applicant ever been placed on probation (academic or disciplinary)?

Yes: ________ No: ________

If the answer to the previous question is yes, clarify the circumstances involved.

______________________________________________________________________________

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