The Ohio State University
Graduate Program Reference Form
To the Applicant
Each recommendation must include the completed Reference Form as well as a separate letter from your recommender written and signed on academic or business
letterhead stationery.
Applicant's Information
Name: ______________________________________________________________________________________________________________________________________________________________________
Last or Family Name/Surname First Middle Date of birth
E-mail address: _________________________________________________________________________________ Major field of study: _____________________________________________________________________
List the name and address of the graduate program to which you are applying.
Admissions
The Ohio State University Fisher College of Business
(graduate program) _________________________________________________________________
100 Gerlach Hall
2108 Neil Ave.
Columbus, OH 43210 USA
If you have had contact with a faculty member at Ohio State regarding graduate study, please indicate the following:
____________________________________________________________________________________ ____________________________________________________________________________________
Faculty contact's name Department
Recommender's Information
Name: ______________________________________________________________________________________________________________________________________________________________________
Title: ___________________________________________________________________________________ Institution: __________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________________________________________
Phone: _____________________________________________
FAX: _____________________________________________________ E-mail: _______________________________________________________
IMPORTANT: At least one direct contact number must be supplied, for verification purposes.
List the courses you have taken under the direction of this recommender:
Course Number Course Title When Taken Grade
___________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
Applicant's Waiver of Right to Access
The Family Educational Rights and Privacy Act of 1974, as amended (P.L. 93-380), allows a candidate for admission, employment, or receipt of honors to waive his or her right of access to
confidential letters or statements written on his or her behalf if the recommendation is used solely for the purposes of admission, employment, or the receipt of honors 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 for
admission or award of fellowship or associateship. However, under the legislation you have the option of signing such a waiver 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 the Graduate School, The Ohio State University, and for award of a fellowship or associateship, if applicable. This
waiver is effective insofar as the recommendation is used solely for the purpose of admission or award of fellowship or associateship, if applicable.
Printed Name: ________________________________________________________ Date: ______________ Signature: __________________________________________________________________________
(continued)
Fisher College of Business