ORIGINAL-Student’s File COPY-Registrar’s FERPA File COPY-Institutional Research
Request For Non-Disclosure of Directory Information
These items listed on the reverse side of this form are designated as DIRECTORY INFORMATION by the Board of
Regents of Higher Education and may be released by the Northwestern Connecticut Community College (NCCC).
Und
er the provisions of the Family Educational Rights and Privacy Act of 1974, as Amended, you have the right to
withhold the disclosure of any or all of the “Directory Information” listed on the reverse side of this form. Please
consider very carefully the consequences of any decision by you to withhold Directory Information. Should you
decide to inform NCCC not to release any or all of this Directory Information, any future requests for such
information from non-institutional persons or organizations will be refused.
NC
CC will honor your request to withhold Directory Information but cannot assume responsibility to contact you for
subsequent permission to release them. Regardless of the effect upon you, the institution assumes no liability for
honoring your instructions that such information be withheld.
Considerations
1. Please give careful consideration to the consequences of withholding directory information. Should you do this,
any future requests for such information, including the fact that you are enrolled, from persons or organizations
unaffiliated with the university will be refused. This information will NOT be released even in emergency
situations. Our response when an inquiry is received about your student record will be, “We have no information
about this person.”
2. NCCC will not contact you when a request for information is made; therefore, if you do wish to have information
released to a specific person or organization while this request is in effect, you must establish a FERPA Consent to
Release for them. No information will be released to anyone, including you, without proof of identity.
3. NCCC will not print your name in graduation, honors and/or awards lists, including newspaper listings if
appropriate. Since nondisclosure stays on your record until you file a written request to remove it, please be
aware that this will prevent disclosure of your information to any and all prospective employers.
4. You must be a registered student during the term for which you are requesting nondisclosure of information.
If you do not want the information on the back of this form to be released, please complete this form and submit
it to the Registrar’s Office, Green Woods Hall Room 215. You must also show a Photo ID.
Student ID # @___________________
Student’s Name:______________________________________________________________
Student’s Address:____________________________________________________________
Student’s Signature:_______________________________________ Date:______________
PLEASE SUBMIT THIS FORM TO THE REGISTRAR’S OFFICE WITHIN THE FIRST TEN (10) DAYS
OF THE START OF THE SEMESTER.
Date Received:_______________ Date Entered Into Banner:_________________ By:__________________
