3050 Martin Luther King, Jr. Drive Phone: (318) 670-9229
Shreveport, Louisiana 71107 FAX: (318) 670-6344
www.susla.edu registraroffice@susla.edu
Students who complete and submit this form for processing are authorizing SUSLA to release data to the
Louisiana Office of Financial Assistance (LOFSA) through the Louisiana Department of Education (LDE) and
the postsecondary education institution(s) to which I apply (Institution) through the Board of Regents (BOR) and
LDE. The student must complete the information as requested below and submit the completed form to the
Registrar’s Office.
NOTE: If the student is currently enrolled, this request will be processed once final grades are posted at the end
of the semester. If not, all academic information, to date, will be provided to LOFSA.
Name: SUSLA ID# 9000
Last 4-digits of SSN: ______________DOB ________________ Phone: ( )
Street Address City ST Zip
SUSLA Email: @skymail.susla.edu Personal Email:
Classification: Is SUSLA your home institution? Yes No
If not, please list your home institution: ___________________________
Are you:
(check all that apply)
Enrollment Date: Year Semester Fall Spring Summer Major: ________________
I, the undersigned, authorize SUSLA to:
Share the following data: full name, birthdate, social security number.
Share my cumulative student transcript data (includes but not limited to, courses taken, type of course,
the grades for each course, and when and where the courses were taken).
Provide academic information so LOFSA can determine whether I am eligible for TOPS and other
college aid using the Louisiana Award System (LAS).
Provide academic information so LOFSA can make TOPS and other aid payments.
Provide academic information so the Institution can process my application for admissions.
Student’s Signature: ______________________________ Date: ___________________________
Registrar’s Office
Academic Authorization Release Request
requesting TOPS grade(s) submission? requesting Chafee grade(s) submission?
requesting Rockefeller grade(s) submission? Other:
Special Sophomore
RO: Academic Authorization Release Request:07/17-LR
Registrar’s Office Use Only
Date Processed:
Processed by:
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