CONFIDENTIAL AND PERSONAL INFORMATION WHEN COMPLETED – Encrypt to transfer | Do not take offsite without authorization
To the Faculty Member or Department Representative:
This form and any personal information accessed in the preparation of the reference must be kept for a minimum of one (1)
year after the reference is complete, but need be kept no longer unless other policies apply.
Consent to Disclosure of Personal Information
Academic Reference Request
This form is to be completed by students requesting an academic reference. Please fill in the form
electronically, and then print and sign it. A completed and signed form must be submitted to each department
from which you are requesting a reference.
Personal information on this form is collected under the authority of Queen’s University’s Royal Charter of 1841, as
amended, and may be used to retrieve your student record, to verify your identity, and to provide proof in
preparing your reference. If you have questions about this collection contact the Privacy Officer, University
Secretariat and Legal Counsel, Queen’s University, Kingston, ON, K7L 3N6, (613) 533-6095.
Student Information
FULL NAME
STUDENT №
Referee Information
DEPARTMENT
FACULTY
MEMBER’S
NAME
OR: ☐ a department representative
I, the above-named student, request that either the above-named referee or a representative of the above-named
department, school, or faculty write a letter of reference and/or respond to a reference check on my behalf. I
understand that in order to write the letter of reference, or respond to a reference check, the referee or
representative of the department, school, or faculty will be required to comment on grades and personal
characteristics relating to my academic and/or employment performance.
I therefore authorize:
Select only one (1) of the following
☐
The representative or referee to access my student file, including academic transcripts and/or clinical
evaluations.
☐
The representative or referee to access my academic transcripts only.
☐
DO NOT authorize access to my student file; comments should be restricted to matters currently
within the referee’s scope of knowledge.
I consent to disclosure of my personal information:
Select only one (1) of the following
☐
To all requests for reference.
☐
Only to the following academic institutions or potential employers:
_______________________________________ __________________________
SIGNATURE DATE
