_______________________________________________________________________________________________________________________________________
Under state and federal law, you may withhold either or both of the following categories of information from public use by reporting
to the MSUM Registrar’s Office no later than the tenth (10
th
) class day of each term. Once a category has been withheld, it will
remain withheld until such a time as the student decides to make available either or both categories of information.
Category I
Student’s name, local and permanent (hometown) addresses, email address and telephone number.
Category II
Major and minor fields of study, class level, dates of enrollment, full-time/part-time status, awards, honors (including Dean’s list),
degree(s) conferred (including dates), previous educational institution(s) and dates attended, past and present participation in
officially recognized activities and sports, height and weight of athletes.
I have decided to withhold the following information:
Category I
Category II
Both Categories
Student Name (print): __________________________________________________________________________________________
Signature of Student: __________________________________________________________________________________________
Student ID: _____________________ Date: ________________________
Return form to:
Minnesota State University Moorhead
Registrar’s Office | Owens Hall 210
1104 7
th
Ave S
Moorhead MN 56563
Phone: 218.477.2565 Fax: 218.477.2941
Email: Registrar@mnstate.edu
Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State System.
Directory Information Suppression
(FERPA)
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