College of Graduate Studies
Tennessee Tech University
PO Box 5012, Cookeville, TN 38505
931-372-3233
Permission to Release Education Record Information
Requested by (Student): Release To (Recipient):
______________________________ ______________________________
LAST NAME FIRST NAME LAST NAME FIRST NAME
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STUDENT “T” NUMBER ORGANIZATION/SCHOOL
______________________________ ______________________________
DATE ADDRESS
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PHONE NUMBER CITY, STATE, ZIP
Education record information to be released:
________________________________________________________________________
Purpose of release:
________________________________________________________________________
I give permission for TTU College of Graduate Studies to release the specified information to
the recipient listed above.
______________________________
STUDENT SIGNATURE
_
___________________________________________
DATE
COLLEGE OF GRADUATE STUDIES OFFICE USE ONLY
Action taken: __ Completed __Filed
______________________________ ______________________________
DATE BY WHOM
Return this form to the College of Graduate Studies Office via mail or scan a copy of the completed form
and email it to gradstudies@tntech.edu
