Name of applicant:______________________________________________

To the applicant: This form should be given to college teachers who are able to comment on your qualifications for graduate work in psychology. You should not request a recommendation from a non-academic person except when you have been away from an academic institution for a long time or when your reference is qualified to comment on relevant activities, such as clinical experience. For the convenience of the person making this recommendation you should include a stamped envelope addressed to:

        Department of Psychology
        Graduate Program Secretary

        901 S National Avenue

        Missouri State University
        Springfield, MO 65897

Under the Federal Family Educational Rights and Privacy Act of 1974, students are entitled to review their records, including recommendations. It is your option to either waive your right to review these recommendations or to not waive your right to review these recommendations. Please indicate your choice of option by marking the appropriate line below and sign your name.

_____ I waive my right to review this recommendation.
_____ I do not waive my right to review this recommendation.

Signature: ___________________________________ Date: ___________________

To be completed by the person providing the recommendation:

Compared to other undergraduate students you have known, how would you rate this applicant's potential for graduate work? (Please circle one.)

• Below Average
• Average
• Very Good
• Outstanding (top 20%)
• Excellent (top 10%)
• Superior (top 2%)

Would you please give us your written evaluation of this applicant's work and potential as a psychologist. You could provide these comments on the back of this form or in a separate letter of recommendation.

Name of recommender: ________________________________________
Signature of recommender: ______________________________________
Position of recommender: _______________________________________
Institutional affiliation: __________________________________________
Address of recommender: _______________________________________
Telephone number: ____________________________________________

Please return this form (and your separate letter of recommendation if you choose to write one) by March 1.

Thank you for your courtesy.