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F
DOCUMENT RELEASE FORM
(NOTARY REQUIRED)
Please complete and submit this form to the Fairmont State University (FSU) Official or Office
identified in Section 1. Please note that this form is not valid without signatures from both the
student and the Notary.
Student Name: _________________________________________________________________
Last First Middle
Address: ______________________________________________________________________
Street
______________________________________________________________________
City State Zip Code
Phone Number: ( ) -
Student ID: Date of Birth: / /
Month Day Year
SECTION 1. FSU Official/Office Which Will Release Designated Education Records:
______________________________________________________________________________
______________________________________________________________________________
SECTION 2. Description of the Designated Education Records to Be Disclosed:
______________________________________________________________________________
______________________________________________________________________________
SECTION 3. Recipient of Education Records:
Person/Entity Receiving Records: ________________________________________________
Address 1: __________________________________________________________________
Address 2: __________________________________________________________________
City and State: __________________________________________ Zip Code: ____________
Phone Number: ( ) -
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I, the undersigned, have read and reviewed this document and expressly authorize the FSU Official
or Office identified in Section 1 to release the education records identified in Section 2 to the
person/entity identified in Section 3. I understand that the FSU Official or Office identified in
Section 1, or a designee thereof, may access and review education records identified in Section 2
upon receipt of this document, and that the FSU Official or Office identified in Section 1, or a
designee thereof, may request additional information from me before records identified in Section
2 are authorized for release to the person/entity identified in Section 3.
The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy
of student’s education records. By signing this document, I understand that:
(1) I have the right not to consent to the release or disclosure of my education records;
(2) I have the right to inspect and review such records upon request;
(3) This consent to release or disclose such records shall remain in effect for this one request
only and may expire sooner, if revoked by me in writing and delivered to the person at the office
named above in Section 1.
(4) Any disclosure of information made by Fairmont State University prior to expiration or
receipt of revocation is not affected by expiration or revocation; and
(5) In order for Fairmont State University to release information to the recipient named below,
this release must be signed by me and a Notary Public.
_________________________________________ ________________________
Student Signature Date
STATE OF _______________________.
COUNTY OF _________________________________, to wit:
The foregoing instrument was acknowledged before me this _____ day of
_____________, 20_____, by __________________________________.
My commission expires: ________________________________.
_______________________________
Notary Public Signature
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