HPAC Student Form 2

Authorization to Send Committee Letter of Recommendation (Form 2)
Student name
I, the undersigned, have made application for admission for the medical schools or other health professions graduate schools listed below. For purposes relating to those applications, I request that the Health Professions Advisory Committee of Grinnell College send my committee letter of recommendation to the institutions at the addresses indicated.

I authorize the HPAC to release information and provide an evaluation about any and all information from my education records at Grinnell College, including information pertaining to my education at other institutions I have previously attended which is a part of my education records at Grinnell College.  The HPAC is authorized to solicit opinions from each of the instructors of record for courses on my transcript as well as the individuals at Grinnell College indicated below.  I further authorize the HPAC to seek confidential information from the Vice President for Student Affairs concerning any conduct or academic honesty offenses at Grinnell College, the severity of the offense, and any penalties imposed.   

I understand further that:  (1) I have the right not to consent to the release of my education records at Grinnell College; (2) except as may be provided by my waiver indicated below, I have a right to receive a copy of any written reference upon request; and (3) that this consent shall remain in effect until revoked by me, in writing, and delivered to the HPAC, but that any such revocation shall not affect disclosures made prior to HPAC's receipt of my written revocation.

Contact Michelle Sears at (641) 269-3172 or by email at searsmic@grinnell.edu if you have any questions.
  
Provide the following information. (Alternate ID Number would be for vet, dental, D.O., etc.)
Social Security Number
AMCAS ID Number
Alternate ID Number


By completing and submitting the required information on this electronic form:
I hereby waive all rights of access which I may have, now or at any time in the future, to any reference provided in response to this request.

Current Contact Information
E-mail
Phone (non-campus)
Mailing Address

Have you received a request for a secondary application?
Yes
No

Do you need your letter uploaded or sent to AMCAS?
Yes
No

This is only for schools that do not participate in the AMCAS system. List the name and complete mailing address of any institution to which you would like your letter sent. Please include any applicable due dates.



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