Fillable Directory Non Disclosure Form 11 11 15

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Directory Non Disclosure Form 11 11 15

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“Directory Information”
1. Name
2. Address
3. All telephone numbers
4. Major Field of study
5. Dates of attendance
6. Previous institutions attended
7. Full/part-time enrollment status
8. Degree/awards received
9. Participation in university activities and sports
10. Weight and height of athletic team members’
11. Photographs
Directory Information Non-Disclosure Form
To: All Students
Under the provisions of the Family Educational Rights and Privacy Act
of 1974, as Amended, students have the right to withhold the
disclosure of the “Directory Information”. The items to the right are
designated as “Directory Information” by the University of West
Georgia and may be released for any purpose at the discretion of the
University of West Georgia.
The institution will honor your request to withhold “Directory
Information” but cannot assume responsibility to contact you for
subsequent permission to release them. The institution assumes no
liability for honoring your instructions that such information be
withheld.
However, if this form is not received in the Enrollment Services Center annually by September 15, it will be assumed that the
above information may be disclosed for the remainder of the current academic year. A new form for non-disclosure must be
completed each year.
To withhold directory information complete and return this form either in person or mail to the Enrollment Services
Center (Parker Hall), 1601 Maple Street, Carrollton, GA 30118 or via fax (678) 839-6439.
Release Authorization
By completing and signing this form, I wish for the university to NOT RELEASE my “Directory Information” and any future requests
for such information from non-institutional persons or organizations will be refused. You acknowledge that your name will be
excluded from all university publications including, but not limited to the Commencement Program and the Honors Day program. If a
future employer requests information confirming you are or have been a student at University of West Georgia, this information will
not be confirmed.
Student Signature (required)
Date
Student Information
Student 917 Identification Number
Permanent Phone Number
Alternative Phone Number
UWG Email Address
Permanent Mailing Address (REQUIRED)
City, State, and ZIP
Created 11/11/15
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Directory Non Disclosure Form 11 11 15

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Completed 15 March 2020

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