Request Form for Medical Student Performance Evaluation

Your letter will be prepared by the Office of Student Affairs and Admissions. Since this letter summarizes your academic record, the writer will have access to your file. Please provide information which can be added to the letter as background information. (Limited to 300 words)

Last Name:

First Name:

E-mail Address:

Awards/Scholarships:

Committees, clubs, or organizations (indicate member or office held):

Class offices held:

Research activities:

Community service activities:

Extracurricular activities:

Significant challenges or hardships encountered during medical school:

Will you participate in ERAS? Yes No

For non ERAS programs, will you submit a list of program directors addresses? Yes No
(Note: Addresses are not needed for ERAS programs.)

Attention Student: Your approval is needed to process your letter. Please check the radio box in lieu of your signature.

Signature Approval

Or download, print, and fax the following form to:
Office of Student Affairs, Attn: Medical Student Performance Evaluation
FAX: (937) 775-3322

Request for Letter (word format) or (pdf format)

You will be notified by e-mail when your letter is ready for review.

For more information contact:
Joyce Baver
Office of Student Affairs
210 Medical Sciences Bldg.
(937) 775-3323
FAX: (937) 775-3322