COMPLETION OF ALL FIELDS REQUIRED FOR PROCESSING
T
HIS FORM MUST BE PRESENTED IN-PERSON - A PHOTO ID IS REQUIRED TO PROCESS THIS DOCUMENT
R
ETURN FORM TO: STUDENT CENTRAL, UPPER LEVEL, MADISON HALL
FAXED COPIES WILL NOT BE PROCESSED
P
LEASE ALLOW 10 (TEN) BUSINESS DAYS FOR PROCESSING
PLEASE PRINT CLEARLY:
NAME: __________________________________ ___________________________ _______
LAST FIRST MI
COUGARID NUMBER: ___________________________ DATE OF REQUEST: _____/_____/_____
DAYTIME TELEPHONE NUMBER: (____)_____________ EVENING TELEPHONE NUMBER: (____)_____________
ADDRESS: __________________________________________________ APT. NUMBER: _______
STREET NAME AND NUMBER
___________________________________________ __________ ____________
CITY STATE ZIP CODE
BELOW IS A LIST OF THE DIRECTORY INFORMATION WHICH WILL BE WITHHELD:
 NAME
A
DDRESS (HOME/PRESENT)
T
ELEPHONE NUMBER (HOME)
P
ROGRAM OF STUDY/TECHNOLOGY
P
ARTICIPATION IN OFFICIALLY RECOGNIZED ACTIVITIES AND SPORTS
W
EIGHT AND HEIGHT OF MEMBERS OF ATHLETIC TEAMS
E
NROLLMENT STATUS (LESS THAN HALF-TIME, HALF-TIME, PART-TIME, FULL-TIME, OVER FULL-TIME, INCLUSIVE DATES AND
SEMESTERS OF ENROLLMENT)
D
EGREES, CERTIFICATES, TRANSFER MODULE AND AWARDS RECEIVED (INCLUDING DEANS LIST AND OTHER HONORS)
M
OST RECENT PREVIOUS EDUCATIONAL AGENCY OR INSTITUTION ATTENDED
S
TUDENT.CSCC.EDU E-MAIL ADDRESS FOR THE PURPOSES OF ELECTRONIC PROXY AND CONDUCTING STUDIES ON BEHALF OF THE
COLLEGE
By signing this form to request directory information be withheld, I understand that the above requested information from
my student record will not be released to anyone without my written consent (this includes relatives, friends, prospective
employers, and all other users of directory information). I also understand that transactions and requests must
be made in person and require a photo ID.
SIGNATURE (REQUIRED): _____________________________________________________ DATE: _____/______/_____
I
NO
LONGER
WISH
TO
HAVE
MY
DIRECTORY
INFORMATION
WITHHELD
. P
LEASE
REMOVE
THE
RESTRICTION
FROM
MY
RECORD
.
SIGNATURE (REQUIRED): _____________________________________________________ DATE: _____/______/_____
FOR OFFICE USE ONLY
Date received: _____/_____/_____ A clear copy of the student’s photo ID, made by the CSCC staff member
receiving the form, must be attached to this form.
Date processed:_____/_____/_____
Processed by: _________________________________________________________
RLR/prc: Request to Withhold From Directory Form/10-24-2019
REQUEST TO WITHHOLD PERSONAL INFORMATION FROM DIRECTORY
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) RESTRICTION PLACED ON RECORD
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