_______________________________________ ____________________
______________________________________________
____________________________________
________________________________ ________________ _______________________________________
____________________
Release Authorization
Student to complete:
Students who are unable to collect their document(s) can use this form authorizing another person
to pick up their document(s).Complete and submit this form
before any documents can be released.
O˜cial documents can only be released to those who have valid photo I.D.
Name:______________________ ______________________________
_______
Date of birth
:______________
Family Name First Name
MI
mm/dd/yyyy
PCC ID#
_________________
E-mail: ______________@
pasadena.go.edu Cellphone # ___________________
last 8 digits
Relationship: ______________________________ Phone Number: _________________________________
Name of person you are authorizing to pick up your document(s):
_____________________________ ___________________________________________ __________
Family Name First Name MI
Name:
I authorize Pasadena City College, I
nternational Student Center to give my document(s) for the request
made to the above-mentioned person and release Pasadena City College, and International Student Center
of any liability.
I state that the information I am providing on this form is true. I further understand that it is a violation of United States law to
give false information to the college.
Student Signature Date mm/dd/yyyy
ISC Staff to complete:
_________________
Print Name – Authorized person picking up document(s)
I.D type / details
Picked up document type / notes
Date
_________________________________________________
Signature - Authorized
person picking up document(s)
Staff initials ________
Important Note: All paperwork requests require 10 business days to process. revised 4/25/2018
