Fillable REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION The (Florida Institute of Technology)

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REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION The (Florida Institute of Technology)

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REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION
The items listed below are designated as directory information under the provisions of the Family Educational Rights and Privacy Act
of 1974, as Amended. These data elements about you may be released to any party for any purpose at the discretion of Florida Tech.
However, you have the right to withhold the disclosure of directory information.
Please consider carefully the consequences of a decision by you to withhold any category of directory information. Should you decide
to inform the institution not to release directory information, any future requests for such information from non-institutional persons
or organizations will be refused except to: certain government agencies/ocials, sponsoring organizations and selected university
personnel on a need to know basis, who have dened legitimate educational interest in such records.
This request to withhold the following directory information will remain in eect until the student named below noties the Oce of
the Registrar otherwise in writing: student’s name, address, telephone number, date and place of birth, major eld(s) of study, e-mail
address, participation in ocially recognized activities and sports, weight and height of athletics team members, dates of attendance,
part-time or full-time status, degrees and awards/honors received and the most recent education institution attended other than
Florida Tech.
o Yes, I choose to prevent disclosure of my directory information.
Student Name __________________________________________________________  Student ID Number __________________________
Last name First name
Student Signature ____________________________________________________ Date __________________________________________
Florida Institute of Technology § Oce of the Registrar § 150 West University Boulevard, Melbourne, FL 32901-6975 § 321-674-8115 § Fax 321-674-7827
Oce of the Registrar Use Only
Operator Initials ___________________________________
Date Processed ___________________________
RGR-461-0220
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REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION The (Florida Institute of Technology)

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Completed 29 January 2021

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