Student ID: @_______________________________________ Phone: __________________________________________
Name: Last _____________________________________ First _____________________________________ M.I. _______
Local Address: _______________________________________________________________________________________
Street City State Zip Code
Please withhold the release of directory information about me until I rescind this request, in writing, to the Oce of
Records and Registration.
Student Signature: ___________________________________________________________ Date: ___________________
Public Law 93-380, Privacy Act of 1974, permits the release, for the purpose of identication and record keeping, of the specic
items listed below unless a student has submitted a written request that this information not be released.
1. Name
2. Address (campus, local or home address)
3. Telephone number
4. Program and concentration(s) and minor(s)
5. Student activity participation; including athletics
6. Weight and height (athletic teams)
7. Dates of attendance
8. Full-time, three-quarter time, half-time or less than half-time enrollment status
9. Anticipated graduation date
10. Class level
11. Degrees and awards received
12. Date of graduation
13. All educational institutions previously attended
14. Academic awards, scholarships, and/or honors received
15. Student photograph
Request for Withholding the Release
of Directory Information
Each student has the right to prevent the release of directory information indicated above by notifying the Oce of Records
and Registration in writing. Such notication must be submitted to the Oce of Records and Registration no later than the
end of the ADD Period” established by the University for each academic semester or session. Once a written request to
withhold information has been received, it will remain in eect until the student rescinds the request in writing to the Oce of
Records and Registration.
Note: Your name will not appear in any ocial University publication, including the commencement program. The Privacy Act
does establish some specic instances in which public information may be released even though you have requested a public
information hold.
Mail or Fax Completed Form to:
Oce of Records and Registration, Edinboro University, Hamilton Hall, 210 Glasgow Rd, Edinboro, PA 16444,
Fax: 814.732.2130, Phone: 814.732.3501
Created: 3/13/2003 • Revised 10/2/2019