AUTHORIZATION TO RELEASE INFORMATION
OFFICE OF INTERNATIONAL STUDENTS & SCHOLARS
Federal law prevents the office of International Students and Scholars (OISS) from releasing information regarding an
international student or scholar to anyone except the student or scholar. If a student or scholar wants information released
to a third party, they MUST submit this Release of Information to OISS.
STUDENT INFORMATION
Last Name: First Name:
Date of Birth:
SU ID:
I authorize the Office of International Students & Scholars to release information / records about me to the following person:
REPRESENTATIVE INFORMATION
Legal Name of Representative:
Relationship to Student: Mother Father Guardian Spouse/Partner Employer
Other Please Specify: _________________________________
Please state what specific information/records may be released to the representative indicated above (i.e. OPT
Information, Notice of Action, Immigration Advising, SEVIS reporting, I-20 pickup, etc.)
INFORMATION AND/OR RECORDS TO BE RELEASED
State the purpose for this release of information and/or records.
PURPOSE
I understand that I have the right to not give consent to the release of my immigration records, that I have the right to
receive a copy of these records upon request, and that this consent shall remain in effect until revoked by me, in writing,
and delivered to the Wayne State University Office of International Students and Scholars. Any revocation shall not affect
disclosures previously made by Wayne State University prior to the receipt of my written revocation. I acknowledge that
this information is released subject to the confidentiality provisions of the Family Educational Rights and Privacy Act (FERPA)
and other applicable federal and state laws and regulations, which prohibit disclosure of educational information without
the specific written consent of the individual to whom it pertains, or as otherwise permitted.
Signature: ___________________________________________________________ Date: _______________________
