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FERPA RELEASE REVOCATION FORM
Student Name:
Last First Middle
Address: ______________________________________________________________________
Street
______________________________________________________________________
City State Zip Code
Phone Number: ( ) -
Student ID: Date of Birth: / /
Month Day Year
I understand that any disclosure of education records made by Fairmont State University prior
to the receipt of this document is not affected by this revocation. I acknowledge that this form
will not be considered valid until a student photo ID is provided to and verified by the faculty
or staff member receiving this request. I further understand that this revocation must be signed
by me and that I must deliver it to the appropriate Fairmont State University Official or Office.
Therefore, I expressly revoke the FERPA Release previously submitted to the following
offices for the following recipients:
FSU Official or Office: ________________________________________________________
Recipient: ___________________________________________________________________
________________________________________ ______________________
STUDENT SIGNATURE DATE
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FACUTLY/STAFF-
Student Photo ID checked: Yes No Initials: __________
click to sign
signature
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