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MLT Reference & Employment Information

Date

Name

Street Address

City State Zip
Phone 111-111-1111
E-mail
REFERENCES
List the names and complete addresses of three persons whom we may contact as your references…..such as an employer, a principal or teacher, and another professional person . . . not relatives
Name & Address Their Professional Position
 
 
   
Name & Address Their Professional Position
 
 
   
Name & Address Their Professional Position
 
 
EMPLOYMENT INFORMATION
 List the following about your last three jobs:
  Position Held Company & City Date of Employment
1.
     
2.
     
3.
     
 

WAIVER
I hereby waive the right to request a copy of completed reference forms from my student MLT file. I do this with the understanding that confidential reference statements are more readily acceptable by prospective evaluators. I understand that these documents would otherwise be available to me through my rights as expressed in the Family Education Rights and Privacy Act of 1974, Public Law 93-380.
Yes No

AGREEMENT
 I submit that the above information is true and accurate to the best of my knowledge.
Yes