Fillable Student Authorization to Withhold Directory Information (State University of New York at Plattsburgh)

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Student Authorization to Withhold Directory Information (State University of New York at Plattsburgh)

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Student Authorization to Withhold Directory Information
SUNY Plattsburgh
The following directory information by will be made available by SUNY Plattsburgh to the general public
unless the student submits written authorization to withhold information to the Registrar’s Office:
Student’s full name
Telephone numbers
Addresses (including email)
Photographs
Date of birth
Major
Honors
Awards
Classification
Dates of attendance
Degrees conferred
Dates of conferral
Graduation distinctions
Institution attended immediately prior to
admission
Under the provisions of the Family Educational Rights and Privacy Act of 1974, you have the right to
withhold disclosure of such directory information. Please consider carefully the consequences of any
decision to withhold directory information (i.e., SUNY Plattsburgh cannot release any information about
you, including but not limited to verification of degree, enrollment verification, Dean’s list, etc.). The
SUNY Plattsburgh response for any student with a confidentiality hold is “We have no information
regarding this individual.”
Enter the effective date for withholding information and the date you permit SUNY Plattsburgh to begin
releasing information. Should you choose not to enter a release date at this time, you must then submit
authorization to remove this confidentiality hold on your record in writing accompanied by a copy of
official identification (e.g., driver’s license, passport, college ID, etc.).
Hold Effective Date: ______________________ Hold Release Date: ______________________
REQUEST:
Student must provide proof of identification (e.g., copy of driver’s license, passport, etc.).
 I hereby request SUNY Plattsburgh to not release directory information. I understand the
consequences of this request.
 I hereby rescind my previous request to SUNY Plattsburgh to withhold directory information.
(Complete if this request is earlier than the date listed above.)
_______________________________________________________ __________________
Student’s Signature Date
___________________________________________ ___________ __________________
Student’s Name – Print last name, first name , MI Date of Birth Student’s ID
Mail to:
Registrar’s Office
SUNY Plattsburgh
101 Broad Street
Plattsburgh, NY 12901
EMAIL: registrar@plattsburgh.edu
FAX: 518-564-4900
VPAA 7/13
FOR OFFICE USE ONLY
Processed by:
Office:
Date:
Submit form to the Registrar’s Office after request
has been processed.
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Student Authorization to Withhold Directory Information (State University of New York at Plattsburgh)

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Completed 27 August 2020

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