Fillable Authorization-for-release-of-information CALIFORNIA STATE UNIVERSITY, CHICO

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Authorization-for-release-of-information CALIFORNIA STATE UNIVERSITY, CHICO

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CALIFORNIA STATE UNIVERSITY, CHICO
STUDENT CONDUCT, RIGHTS & RESPONSIBILITIES
, give my consent for
Name (Please Print / Type)
the office of Student Conduct, Rights & Responsibilities or other University staff at
California State University, Chico to release any information for the purpose
of
discussing all matters pertaining to my discipline/grievance case with:
Name
Relationship
Address
Name
Relationship
Address
Name
Relat
ionship
Address
Signature
Student ID Number
Date
This authorization is valid for 6 months from the date of signing. Expires:
Any information shared with the individual authorized to receive information is confidential and may
not be shared with a third party.
Please return form to:
SSC 190 or scrr@csuchico.edu
Name
Relationship
Address
I,
AUTHORIZATION FOR RELEASE OF INFORMATION
5/21/2019
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Authorization-for-release-of-information CALIFORNIA STATE UNIVERSITY, CHICO

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Completed 17 November 2019

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