Fillable Privacy Request Form 6004 S County Rd G (Blackhawk Technical College)

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Privacy Request Form 6004 S County Rd G (Blackhawk Technical College)

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6004 S County Rd G • PO Box 5009 • Janesville, WI 53547-5009
(608) 757-7660 • fax (608) 743-4407 • registration@blackhawk.edu
Last Revised: 12/9/2019 1
Privacy Request Form
I, ___________________________________________, BTC Student ID Number __________________,
Student Name
request that Blackhawk Technical College (BTC) withhold all information, not limited to directory
information. I understand this will be in place until I direct BTC, in writing, to do otherwise. Any information
requested pertaining to me will require a photo identification (i.e. state identification, driver’s license, or
BTC identification card) and a signature confirmation for authenticity.
This form must be completed in the presence of a BTC employee and cannot be mailed, faxed, or
submitted by another person on behalf of the requestor.
______________________________________________ _________________________
Student Name (Printed) Dated
______________________________________________
Student Signature
I no longer request that BTC withhold all directory information, effective _____________________.
Date (DD/MM/YY)
______________________________________________ _________________________
Student Name (Printed) Dated
______________________________________________
Student Signature
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Privacy Request Form 6004 S County Rd G (Blackhawk Technical College)

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Completed 27 July 2020

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