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Letter of Recommendation for Residency Authorization Form

I, _____________________________________ am requesting a letter of

recommendation for residency from _________________________________. I

acknowledge that this letter is for the specific purpose of supporting my application for a

residency and therefore give permission for you to discuss my academic and personal



____ I waive my right to see this letter under the “Family Rights and Privacy Act.”

Please address the letter to “Dear Program Director” or “Dear Colleague” and place

on letterhead. Email the letter as a PDF attachment (on letterhead and

signed) to

You may alternately mail the letter to the following address:

Office of Student Affairs

Suite 100, Stemmler Hall

3450 Hamilton Walk

Philadelphia, PA 19104-6087


Thank you for supporting my application for residency.

Signed ___________________________________________ Date____________


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