Student Reference Request Authorization

Montana Code Annotated (MCA) 20-25-515 is very specific with regard to release of student records:

“A university or college shall release a student’s academic record only when requested by the student or by a

subpoena issued by a court or tribunal of competent jurisdiction. A student’s written permission must be

obtained before the university or college may release any other kind of record unless such record shall have

been subpoenaed by a court or tribunal of competent jurisdiction.”

Instructions for the student: Completely fill out this form. Note that you can modify this authorization by

crossing out parts of the text or adding additional text (please initial any changes you make).

I, __________________________________ (printed name), Student ID Number ___ 790 - _________________ ,

hereby give my permission for __________________________________ to provide a written or oral reference

on my behalf.

I authorize the above person to release information and provide an evaluation about any and all aspects of my

academic performance (including grades, GPA, class rank, etc.) and/or employment performance at the

University of Montana to the following (check or circle your choices):

1. Prospective employers:

___ALL ___NONE ___SPECIFIC EMPLOYERS listed on reverse side or sent by email

2. Educational institutions to which I seek admission:

___ALL ___NONE ___SPECIFIC INSTITUTIONS listed on reverse side or sent by email

3. Organizations considering me for an award or scholarship:

___ALL ___NONE ___SPECIFIC ORGANIZATIONS listed on reverse side or sent by email

This authorization is valid for one year unless a different ending date is specified below, or written revocation is

received from the student.

Ending date (optional): ___________________________

Note: Under the Family Educational and Privacy Rights Act (FERPA), 20 U.S.C. 1232(g), you may, but are not

required to, waive your right of access to confidential references given for any of the purposes listed above. If

you waive your right of access, the waiver remains valid indefinitely.

I waive my right of access: ___YES ___NO

Signature: ___________________________________________________ Date: _________________________

[This form must be kept on file for five years after the student’s last date of enrollment at UM.]