Referral Consent Form

I have requested a letter of referral from Dr. Graham Higgs and in doing so I hereby consent to his disclosing my academic history and any information related to my performance as a scholar. This may include my involvement or performance in both curricular and co-curricular activities and my personal qualities as they relate to future success. I also give my permission to Dr. Higgs to disclose this same information in verbal conversations.

To assist in my evaluation, I offer my perspective on the items below:


I attended the following courses in which Dr. Higgs was the professor:







Some of my strengths as a student include:






Personal or professional characteristics that I would like to have included in a reference: 







My goals for the future that relate to this recommendation request:








Signed: __________________________________ Date: ______________