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.