Student Financial Services 1500 College Parkway Elko, NV 89801 775.753.2399
Email: financial-aid@gbcnv.edu Web site: www.gbcnv.edu/financial
AUTHORIZATION TO DISCLOSE EDUCATIONAL RECORDS
and
CERTIFICATION
I, ______________
_________, hereby authorize Great Basin College to release my education records,
including directory and non-directory information and records pertaining to my application for financial aid, to
Great Basin College Foundation until I withdraw this authorization.
The released education records will be used for the purposes of evaluating my eligibility to receive
scholarships, correspondence with scholarships donors, and press releases relating to scholarships recipients.
I expressly authorize Great Basin College Foundation to disclose my education records for these purposes.
I understand that by signing this authorization, I am waiving my rights of nondisclosure of these records
under federal law only as to the person or persons specifically listed. This release does not permit the disclosure
of these records to any other persons or entities without my written consent.
Additionally, I give Great Basin College and Great Basin College Foundation permission to use my
photograph/video for the purpose of publicity associated with scholarships awarded. This release is intended to
discharge any and all claims and demands arising out of or in connection with the use of photography/video in
which my image appears, including any and all claims for libel or invasion of privacy. I hereby grant Great Basin
College and Great Basin College Foundation the ownership and full use of any photographs/videos that are taken.
I certify that all information I have provided on the GBC Scholarship Application is true and complete to the
best of my knowledge. I acknowledge that if I am selected to receive a scholarship, it is my responsibility to
understand the requirements of the specific scholarship.
Date________
____________ Print Name: ______________________________________
Student’s Signature________________________________
Student’s GBC ID (ten digit) #:______________________________
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