AUTHORIZATION FOR RELEASE OF INFORMATION
Name ____________________________________________ SS# __________________
(Please Print) Last First Middle
Classification ______________________________________ Major ________________
I am requesting the following information:
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_____ Enrollment Verification for: ____ Health Insurance ____ Loan
____ Fall ____ Winter ____ Spring ____Summer
_____ History of Enrollment: (Includes all dates of attendance)
Letter will include the following:
Full, half, or part-time enrollment status
Anticipated date of graduation
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____ Letter for “Good Student Discount” (auto insurance)
Student must have a GPA of 3.000 or better
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____ Letter of academic standing to be mailed to another school:
School & Address _______________________________________________
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_______________________________________________
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Student must be in good academic standing
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____ I would like the information faxed or mailed to:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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____ I will pick up the information requested
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Signature of Student Required Date of Request
2/2002-REGISTRAR-BD