Principal or College Advisor Reference Form
TO THE APPLICANT: Please fill in the information below and give this form to your principal or college
advisor (counselor).
NAME OF APPLICANT: ____________________________________________________________
WCM-Q APPLICANT ID #: _____________
TELEPHONE (with country code): ___________________________
E-MAIL ADDRESS: _______________________________________
Applicants who are admitted and enroll at Weill Cornell Medicine-Qatar (WCM-Q) have the right, under
the Family Educational Rights and Privacy Act of 1974 (FERPA), to see written evaluations submitted on
their behalf, unless they have waived that right. Please indicate your choice below by checking the
corresponding box and signing below. Your choice will not be a factor in considering your application.
Please check one of the options below:
_____ I waive my right to see this letter.
_____ I do not waive my right to see this letter.
APPLICANT’S SIGNATURE: __________________________________ DATE: _________________
____________________________________________________________________________________________
TO THE PRINCIPAL/COLLEGE ADVISOR: Please fill out all of the sections and return the entire
Principal/College Advisor Form to the address indicated on the last page. We appreciate your time and
effort in filling out this evaluation, as your reference is critical in our assessment of the suitability of this
applicant for admission to our program.
NAME: ______________________________________________________________________________
TITLE: ____________________________________________
TELEPHONE (with country code): _______________________
E-MAIL ADDRESS: ___________________________________
SELECT YOUR ROLE: _____Principal _____College Advisor/Counselor
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NAME OF APPLICANT: _______________________
WCM-Q ID #: ______________________________
SCHOOL NAME: _______________________________________________________________________
ADDRESS OF SCHOOL
STREET: _______________________________________ CITY: ____________________
STATE: _____________ POSTAL CODE: __________ COUNTRY: _____________________
How long have you known the applicant?
_________________________________________________________________________
GRADE POINT AVERAGE
1. The applicant’s overall Grade Point Average (GPA) is __________________________
2. The applicant’s GPA is based on a point scale of ______________________________
3. This applicant’s GPA is (Select One) _____ Weighted _____ Not Weighted
CLASS RANK (Comparative Performance within a graduating class, as measured by overall Grade Point Average)
1. The number of students in the graduating class is ______________________________
2. This applicant’s rank is (Select One) _____ Weighted _____ Not Weighted
3. This student’s rank number is _________________
4. How many graduating seniors have higher rank than this applicant? ________________
5. If a precise rank is not available, please indicate the approximate ranking of this student
(i.e. top 10th, 20th, 30th, etc.) ___________________________________________________
6. What percent of students continued on to university from the previous class? ________
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NAME OF APPLICANT: _______________________
WCM-Q ID #: ______________________________
RATING
Compared to all of the other university-bound students you have known, how do you rate this applicant
in terms of the following?
No Basis
General Ratings Top 5% Top 15% Top 25% Upper Half Lower Half
For Rating
Academic
Potential
Character and
Personal Potential
SCHOOL INFORMATION
1. Please rate the overall rigor of the academic program undertaken by this student, compared with
that of his or her university-bound classmates (Select One)
STANDARD ADVANCED MOST RIGOROUS
2. Does your school offer its students AP, A-Level, or IB courses? (Select One)
YES NO
3. If YES for Question 2 above, how many courses? (Select One)
1-3 4-5 6 - 10 11 OR MORE
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NAME OF APPLICANT: _______________________
WCM-Q ID #: ______________________________
Please write a summary report and recommendation in support of this student’s application to the Six-
Year Medical Program at Weill Cornell Medicine-Qatar (WCM-Q). You may attach a separate letter with
this reference and indicate that accordingly in the space below.
Please appraise the applicant’s academic and personal qualities. Discuss the applicant’s special talents
and characteristics, commitment to academic work, non-academic achievement, and specific events or
unusual circumstances that may have affected the applicant’s performance in secondary school. Please
provide us with any information you feel is useful in helping us assess this applicant’s ability to succeed
in our program.
SIGNATURE OF REFERENCE: _______________________________ DATE: __________________
PLEASE SEND THE ENTIRE PRINCIPAL/COLLEGE ADVISOR REFERENCE FORM IN A SCHOOL SEALED
ENVELOPE DIRECTLY TO:
OFFICE OF ADMISSIONS
WEILL CORNELL MEDICINE-QATAR
AL-LUQTA STREET, P.O. BOX 24811,
QATAR FOUNDATION – EDUCATION CITY
DOHA, QATAR
TELEPHONE: +974-4492-8500
E-MAIL: [email protected]
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