Fillable REQUEST TO WITHHOLD DIRECTORY INFORMATION (California State University, Dominguez Hills)

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REQUEST TO WITHHOLD DIRECTORY INFORMATION (California State University, Dominguez Hills)

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FOR OFFICE USE ONLY
PLACE DATE STAMP HERE
REQUEST TO WITHHOLD DIRECTORY
INFORMATION
OFFICE OF ADMISSIONS AND RECORDS (WH 290)
FOR OFFICE USE ONLY
Processed By:
Date:
Last Updated: March 23, 2020
STUDENT ID:
PHONE NUMBER:
LAST NAME:
FIRST NAME:
ADDRESS:
CITY:
STATE:
THIS FORM MAY ONLY BE SUBMITTED BY THE STUDENT
Instructions: This request becomes effective beginning the semester it is submitted through the end of students'
academic tenure at the university. Students who wish this request to be withdrawn must submit their request in
writing. Before signing this form, you should carefully read the following:
This form will prevent the Office of Admissions and Records from verifying any directory information
regarding your record to anyone, including yourself, over the telephone or in writing without your signed,
written consent.
This form will prevent verification for purposes of employment, loans, credit card applications and
insurance.
Always bring picture identification with you for in-person inquiries. We will not release information
without positive identification.
Students who obtain a campus e-mail account should be aware that name, student status and e-mail
addresses cannot be withheld from Internet access.
If, after having considered this information, you would like to request that directory information be with-held,
please sign and date the form below and return this completed form to:
Office of Admissions and Records
Attention Records & Registration Unit
CSU Dominguez Hills
1000 E. Victoria Street
Carson, California 90747
PRIVACY DECLARATION
I hereby request that the public directory information as described in the current University Catalog under Privacy
Rights of Students in Education Records, not be released. I understand that this request is valid from the
semester submitted through the end of the student’s academic tenure at the California State University,
Dominguez Hills.
_________________________________________ _________________
Student Signature Date
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REQUEST TO WITHHOLD DIRECTORY INFORMATION (California State University, Dominguez Hills)

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Completed 18 August 2020

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