STUDENT NAME: _________________________________ PURDUE GLOBAL STUDENT ID OR LAST 4 DIGITS OF SSN: ___________
EMAIL ADDRESS: _______________________________ STUDENT SUPPORT SPECIALIST (OPTIONAL): _______________________
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Student Signature: ______________________________________________________________ Date: ___________________________
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
ACADEMIC HEADQUARTERS
550 West Van Buren Street
Chicago, IL 60607
ONLINE
Tel: 844-787-3834 (Toll Free)
AUGUSTA
Tel: 207-213-2500
CEDAR FALLS
Tel: 319-277-0220
CEDAR RAPIDS
Tel: 319-363-0481
DAVENPORT
Tel: 563-355-3500
DES MOINES
Tel: 515-727-2100
HA
GERSTOWN
Tel: 301-766-3600
INDIANAPOLIS
Tel: 877-320-5430
LEWISTON
Tel: 207-333-3300
LINCOLN
Tel: 402-474-5315
M
ASON CITY
Tel: 641-423-2530
MILWAUKEE
Tel: 414-223-2105
OMAHA
Tel: 402-431-6100
ROCKVILLE
Tel: 301-258-3800
ST. LOUIS
Tel: 314-205-7900
Family Educational Rights and Privacy Act (FERPA) —
Directory Information Withholding Request Form
OVERVIEW
Under FERPA, Purdue University Global may release “directory information” to third parties without student consent. The University designates the
following categories of student information as directory information:
• Name
• Addr
ess
• Telephone number
• Email address
• Photographic representations of students
• Field of study
• Grade level
• Enr
ollment status
• Dates of attendance at the University
• Degrees, honors, and awards received
• Participation in ocially recognized campus activities
Currently enrolled students may choose to withhold disclosure of directory information by submitting this form. Students should consider very
carefully the decision t
o withhold directory information. Purdue University Global will honor requests to withhold directory information upon
approval and processing of Directory Information Withholding Request Forms and as such cannot assume responsibility to contact students for
subsequent permission to release information to prospective employers, relatives, and other persons.
INSTRUCTIONS
To request that your directory information be withheld from third parties or to rescind a prior request to withhold directory information, complete
this form. Be advised that processing this form may take up to 6-8 business days from the date of receipt. Incomplete forms will not be processed.
To complete this form, input all required information and electronically initial and sign where required. When the form is complete, click Finish to
submit it to the University. Please ll out the form completely and accurately to avoid potential delays in processing.
If you are unable to electronically initial and sign the form, or have any questions, please contact your Student Support Specialist toll free at
866-522-7747 for assistance.
Learning Center students must submit this form via email attachment to rsupport@kaplan.edu or via fax to 800-588-4127.
Campus students must submit this form to their onsite Oce of the Registrar.
STUDENT INFORMATION
Check ONE of the statements below.
I request that the I
nstitution withhold my directory information from any third parties. I agree that Purdue University Global will
assume no liability as a result of honoring my instructions to withhold directory information from third parties.
I rescind my prior request for the Institution to withhold my directory information and agree that my directory information can be
shared with thir
d parties.
DIWR (2182) Rev 03/2018
