Prohibit Release of Directory Information
(Please PRINT rst name, middle initial and last name)
I, ______________________________________________________ hereby request that my Directory Information
listed below NOT be released to a third party without my written consent, except for those instances specically allowed by
1. Student's name
2. Number of credit hours enrolled
3. Major eld of study
4. Dates of attendance
5. Degrees, honors, and awards received
Student's Signature: ________________________________ SIS ID __________________ Date: ___________________
Processed by: ___________________________________ Date: ______________________
is form must be delivered in person with proper identication.
Please be advised that this request will remain in eect indenitely until such time that you rescind it in writing.
WC 10/12/17
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