Please Read Carefully
Signing the attached "Request to Withhold Directory Information" form will:
Mean your presence on campus will no longer be acknowledged to anyone.
Prevent campus offices from verifying any information regarding your record to
anyone, including yourself, over the telephone or in writing without your written
consent. If a call about your record is received, the following response will be
given: "There is no information available on that person."
Prevent your name from appearing in the commencement program
Consider carefully that this will stop any verification for purposes of employment,
loans, credit card applications, insurance, etc. Anytime you need to contact us, it will
have to be in writing or you will need to bring your I.D. to Room 1220 Old Main and
inquire in person.
Students who obtain a personal electronic mail account through the University
should be aware that their name, student status and e-mail address cannot be withheld
from internet access.
The revocation of this restriction must be in writing. The request for revocation
should include your name and E-number, your written signature and a copy of a photo
identification card or drivers license, if the request is mailed to us. If you present the
request in person, you will be asked to present a photo identification card or drivers
license before the restriction will be removed.
If after having read this information, you still want to place a privacy restriction
on your record; complete the attached form and return it to an Office of The Registrar
staff member.
REQUEST TO WITHHOLD INFORMATION
Under the provisions of the Family Educational Rights and Privacy Act of 1974, as amended, you have the right to
withhold the disclosure of ALL "Directory Information”.
Please consider very carefully the consequences of any decision by you to withhold "Directory Information." Should
you decide to inform the institution not to release this "Directory Information," any future requests for such information
from you, non-institutional persons or organizations will be refused.
Please note: Signing this form will prevent any information regarding your record being verified to anyone,
including yourself, over the telephone or in writing without your written consent. It will also prevent your name
from appearing in the commencement program. If you want your name to appear, you must revoke this
statement, in writing, prior to the graduation application deadline for the semester in which you plan to
graduate.
In accordance with the provisions of the Family Educational Rights and Privacy Act of 1974 as amended, the Eastern
Illinois University policy applying to the same, and the public notice given to all students by the University, I herein
request that certain information applying personally to me not be used as directory information without my prior
approval.
Name under which records are to be found:
_____________________________________________________________________________________
(Last) (First) (Middle) (Previous Name(s)
ID#_____________________________ Birth Date____________________________
Local Address: ___________________________________
Cell Phone:___________________
___________________________________
(City) (State) (Zip)
Home Address: ___________________________________
Home Phone:_____________________
___________________________________
(City) (State) (Zip)
_____________________________________________ ___________________________
(Student's Signature) (Date)
Note to student: If this release is being sent by mail, a copy of your photo i.d must accompany it.
If presenting this document in person, bring your photo i.d. with you.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome