Fillable Authorization for Release of Student Transcripts for Third (University of Texas at Tyler)

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Authorization for Release of Student Transcripts for Third (University of Texas at Tyler)

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Rev. 02.20.2020
Questions regarding data collected may be directed to the Office of the Registrar. (HB 1922)
Notice about Information Laws and Practices
With few exceptions, you are entitled on your request to be informed about the information The University of Texas at Tyler collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code,
you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have The University of Texas at Tyler correct information about you that is held by
us and that is incorrect, in accordance with the procedures set forth in The University of Texas System Business Procedures Memorandum 32. The information that The University of Texas at Tyler collects will be
retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
The University of Texas at Tyler
Office of the Registrar
3900 University Boulevard
Tyler, TX 75799 • (903) 566-7180 • enroll@uttyler.edu
Authorization for Release of Student Transcripts for Third Party Pickup
Name: ______________________________________ Student ID Number: ________________________
Date: _____________ Phone Number: _______________ Alt. Phone Number: _______________
I authorize The University of Texas at Tyler to release copies of my transcripts to the third party designated
below. I understand that:
• I must provide this form and a valid photo ID (Ex. Driver’s License, UT Tyler Student ID, Military ID) via
in-person delivery, fax, or Patriot email prior to the arrival of the designated third party on campus.
• The designated third party must provide their own valid photo ID before documents will be released.
• The designated third party will not be allowed to view my transcripts before they are sealed.
• No more than five transcripts total may be released in a single day.
• This release form is valid for only a single use by a single third party.
• Any holds that block transcripts will prevent processing of this form. Third parties will not be given
details about any holds.
• This form will not be processed if there are any discrepancies in the information I provide and the
information provided by the third party at the time of pickup.
Name of Designated Third Party as it Appears on Their Photo ID:
__________________________________________________________________________________________________
(First) (Middle) (Last)
Number of Official Transcripts to be Released: □ One □ Two □ Three □ Four □ Five
Number of Unofficial Transcripts to be Released: □ One □ Two □ Three □ Four □ Five
Student Signature: __________________________________________ Date: _____________________
Return this form to the One-Stop Service Center (STE 230) or email to Enroll@uttyler.edu
University Officials Only:
Student’s Photo ID Verified: ____________
Third Party’s Photo ID Verified: ____________
Transcripts Sealed and Released: ____________
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Authorization for Release of Student Transcripts for Third (University of Texas at Tyler)

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Completed 30 August 2020

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