Permission for One-Time Release of Education Records
Purpose: used by current and former students to authorize the one-time release of a portion of their education records to a third party by Marquette personnel.
Student Instructions
1. Complete Sections 1-3 of this form using a computer.
a. a handwritten form will not be accepted.
b. an incomplete form will not be processed and returned to you for completion.
2. Print the form using the 'Print Form' button.
3. Sign the form in Section 4; a digital signature is not acceptable.
4. Submit the completed form to the individual named in Section 2.
NOTE:
a. enrollment/degree verification and transcripts will not be released using this form. See Marquette Central Academic-Forms
to request these.
b. this is a one-time release. A new form is needed each time you wish to release your academic record.
c. the individual named in Section 2 has 45 days to respond to this request.
d. prepare a different form for each third party to whom you wish to release your academic record.
@marquette.edu
Records listed above released on this date:
Signature
Rev. 1/2018
Signature of Student Date
Section 5: Individual Releasing Academic Record
complete this section and send to the college/school office of the student
Section 1: Student Information
Name
Last name, First name Middle name
MUID
Date of Birth
MM/DD/YYYY
College/School
PhoneEmail
Section 3: Third Party Information
Title
Name
Last name, First name, Middle name
Rationale for this request
Address
street, city, state, zip code (country if international)
Section 4: Student Statement/Signature
Pursuant to Marquette's FERPA policy, I hereby authorize the above named Marquette staff/faculty to release the information described in Section 2, to the third party designated in
Section 3. I understand this permission is a one-time release and I must make another request each time I wish to release any academic information in the future. Furthermore, I
acknowledge that the individual named in Section 2 has 45 days to comply with this request.
Currently enrolled
Yes No
If no, when were you last in attendance?
ex: Fall 2000
Section 2: Information to be released
Release the following information
(specify every item of information you are authorizing for release)
Organization/Agency (if applicable)
Name the MU personnel who may release the information (Last name, First name Middle name)
