Student Record Release Authorization
I, ___________________________________ hereby authorize Cerritos College to release information
contained in my student record(s) per the provisions, purposes and/or limitations listed below to the
following designee: ___________________________ (Designee must bring in photo identification.)
Type of Information requested (check one):
Transcript
Enrollment Verification
Degree
Receipt
Other (be specific):
______________________________
The Purpose(s) of this authorization are (check one):
At the discretion of the aforementioned designee.
Limited to the following (be specific):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________
(Legal Student Signature)
_____________________
(Student ID Number)
_____________________
(Date)
In accordance with General Education Provisions Act 438, Title IV, Public Law 90-247
and California Education Code, Sections 76240-76246, we must have written authori-
zation from the student to release information regarding educational records.
Students: Please complete this form and have your designee submit it to the office of
Admissions, Records, & Services.
Designee: Must bring in a valid form of photo identification.
Office of Admissions, Records, & Services
Refund
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