LETTER OF RECOMMENDATION FORM

University of Rochester

University of Rochester Medical Center

Eastman Institute for Oral Health

625 Elmwood Avenue

Rochester, New York 14620-2989 USA

(585) 275-8315

LETTER OF RECOMMENDATION FORM

Send this form to the person who is writing on your behalf. A pre-stamped and pre-addressed envelope should be included with each of the Letter of

Recommendation form. The envelope should be addressed to the Residency Coordinator at the address noted above.

PART 1 ~ Applicant should complete this section:

I, _______________________________________________________________________________________________________am

FIRST MIDDLE LAST

applying to the ______________________________________________________________ at the Eastman Institute for Oral Health.

PROGRAM OF STUDY TITLE/NAME

I do ________ do not ________ agree to waive my right under The Family Education Rights and Privacy Act of 1974 to review

specific and composite letters of recommendation.

________________________________________________________________________________________________________________________

Name (printed) Signature Date

Name of individual writing recommendation: ___________________________________________________________________________________

Print Name

PART 2 ~ Individual writing the recommendation should complete this section:

The Admissions Committee would appreciate your individual comments of the applicant’s preparation, aptitude, initiative and creativity necessary

for independent work and the motivation or strength of commitment to the professional career implied by this program of study. If you have taught

the applicant, your comparison of the applicant to other students who have done postdoctoral work elsewhere would be valuable.

Please return your recommendation as soon as possible as the Committee considers these letters a vital part of the application process. Please feel

free to use separate sheet of paper if needed.

How long have your known the applicant? __________________

In what capacity? ___________________________________________________________________________________________________

How would you rate the applicant among the students at a similar level that you have known in recent years?

Upper 10% ________ Upper 25% ________ Upper 50% ________ Lower 50% ________

Letters of Recommendation – EIOH Educational Training Programs Page 1 of 2 Revised Mar 2014

__________________________________________________________________________________________________________________

APPLICANT’S FIRST NAME MIDDLE LAST NAME

Letters of Recommendation – EIOH Educational Training Programs Page 2 of 2 Revised Mar 2014

PART 2 (continued)

If known, please give this student’s average class standing _______________ out of _______________ (class size).

Please complete the following assessment of the applicant:

Excellent

Good

Average

Below Average

Unknown

Personality & Manners

Scientific Performance

Clinical Skills

Industry

Reliability

Initiative

Cooperation

Empathy & Compassion

Personal Hygiene & Neatness

Please provide your comments on the applicant’s personal demeanor and professional aptitude for the program.

________________________________________________________________________________________________________________________

This student is: ________ Recommended ________ Highly Recommended

________________________________________________________________________________________________________________________

Name (printed) Signature Date

Position, profession or occupation: ___________________________________________________________________________________________

Professional address: _____________________________________________________________________________________________________

Business/Company Name

________________________________________________________________________________________________________________________

Street City State Zip Country

Phone Numbers:

Work

Fax