Instructions: This form is to be completed by a student who currently has a block on the release of his or her directory information.
The purpose of this form is to keep the directory information blocked, while allowing a one-time exception to the block. This form
may be used for many purposes. Some of the more common uses include allowing a student’s name to appear on the Dean’s List or
A-Pin list for a specic college or allowing a student’s name to appear in a graduation program. Complete the form with all applicable
information and return it to the Registrars Ofce. Do NOT sign the form until you are in the presence of a staff member of the Regis-
trars Ofce, Financial Aid Ofce, or a Notary Public. A photo ID is required. Present the form to the Registrars Ofce, TSC 246.
Directory (Public) Information includes:
Name, User ID (A-Number), local and permanent address, electronic mail address, telephone number, date of birth, residency status,
degrees and awards received, most recent institution attended by the student, academic level, major eld of study, department or col-
lege, enrollment status (undergraduate or graduate, full-time or part-time), participation in ofcially recognized activities/sports, dates
of attendance and graduation, weight/height of members of athletic teams, and photographs.
Student Information
I hereby declare that, although I currently have the release of my directory information blocked and intend to keep it blocked, I give
my permission to Utah State University to release my information on a one-time basis according to my directions below. I understand
that as long as I continue to keep my directory information blocked, I must ll out a new form every time I want any directory infor-
mation released.
(Student Name) (A-Number) (Birthdate)
Please indicate below specically what information you are allowing Utah State University to release, for what purpose, and for which term, if ap-
plicable. (e.g., I allow the release of my name and major to appear on the Dean’s List website and other places where this list may be printed for the
College of HASS for Fall Semester 2008.)
(Student Signature) (Date)
If you are not completing this form in the presence of a Utah State University Registrars Ofce or Financial Aid Ofcial, this form
must be notarized. The original notarized form must be submitted to the Registrar’s Ofce in order to be valid.
Witnessed by Registrars Ofce or Financial Aid Ofce Ofcial:
Notary Signature: Date:
Last updated: 1/29/2009