Information Release Authorization
Print clearly or type.
Use this form to authorize NGTC to release information from student records.
Read, complete, print, and sign this form, then submit to the registrar’s office by:
Email: r e g i s t r ar @ n o r t h g a t e c h . e d u
Fax: 7 0 6 . 7 5 4 . 7 7 7 7
Mail: NGTC Registrar’s Office, PO Box 65 Clarkesville, GA 30523
Hand: Deliver to the receptionist on any NGTC campus
I hereby request and authorize North Georgia Technical College to release
ANY AND ALL information from my North Georgia Technical College records
ONLY THE FOLLOWING information from my North Georgia Technical College records
List:
to the following individual(s):
Individual’s First and Last Name
Relationship to Student
Examples:
Ginger Little
GA Mountains Workforce Development
Case Manager
John and Mary Smith
Family
Parents
All information I hereby authorize to be obtained from this person or agency will be held strictly confidential and cannot be
released without my written consent. I understand that this authorization will remain in effect until I cancel it in writing.
Student’s
Printed Name:
Student ID # or
Last 4 digits of Social Security #:
Student’s
Signature:
Date:
As set forth in the student catalog, North Georgia Technical College does not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age,
political affiliation or belief, genetic information, disabled veteran, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law). For
complaints or information, contact Mike King, VP of Student Affairs (706- 754-7711, Title VI, IX, II), or Kay Morgan, special services contact (706-754-7828, Sec. 504/Title I/ADA) at 1500
HWY 197 N, Clarkesville, GA 30523.
This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the
information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. 9/14/16
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