Admission and Records
Phone: (541) 383-7500
Fax: (541) 318-3700
2600 NW College Way • Bend, Oregon 97703
Rev date: 04/2019 Office use only: ID Verification _______
Student Name
Street Address
City, State, & Zip
Current Phone
Current College policy allows the release of certain information on students, called "directory information." This
includes name, mailing and email address, telephone number, enrollment status, major, degrees and honors
conferred, dates of attendance and most recent previous school attendance. The policy is described in detail in
the College Catalog on COCC’s website.
By completing and submitting this form to COCC’s Admissions and Records office you are requesting that such
directory information not be released to anyone, including announcements to newspapers of graduation or
honor roll status, no listing in commencement program and no loan/credit certification.
Additionally, this request prohibits COCC faculty and/or staff from discussing your admissions, registration,
financial aid, payment or other status over the telephone and all business will need to be conducted in person,
by you, with picture ID required. As a current student, you can still access your online student services account
for registration, payment, financial aid and related activities (online access expires after one year of no
enrollment activity). Please note that directory information will be used for internal and confidential College
reports, campus research and college business related mailings.
This request remains in effect until you submit the signed Request to Remove Non-Disclosure Hold on Student
Account form, in person with your Student ID, indicating that directory information may be released.
Student Signature: Date:
Return this form in-person with photo identification, or a notarized copy via certified mail, to the Admissions
and Records office on the Bend, Redmond, Prineville or Madras campuses.
click to sign
click to edit