Medical Professions Committee Reference
Letter Waiver Form
Eastern
Applicant’s Name: (Print) _____________________________________________
The letter written by the evaluator is confidential to the extent permitted by law. The applicant may waive or not waive the right of access to information contained in the letter.
Please Check the Appropriate Box:
I waive the right provided by the Family Education Rights and Privacy Act of
1974 (Buckley Amendment) to view this letter of evaluation.
I do not wish to waive this right. Rather, I wish to retain the right to view this letter.
Applicant’s Signature: ________________________________________________