UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration Request to Prevent Disclosure of Directory Information
Please complete, print (see "Print Form" button above), sign, and return this form to the Office of Records and Registration, University Hall, One
University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Forms are processed on a weekly basis. Please be sure to carefully complete all
information prior to printing the document.
Last Name First Name
UIN
Records (217) 206-6709 Degree Audits (217) 206-8216 Registration (217) 206-6174 Graduation (217) 206-7730
For Office Use Only
Processed By:
Date:
Student Signature
Under the provisions of the Family Educational Rights and Privacy Act of 1974, as amended, you have the right to withhold the disclosure of any
"Directory Information" (information which is available to the public).
Date
Please consider very carefully the consequences of any decision by you to withhold Directory Information. Should you decide to inform UIS
not to release Directory Information, requests from non-institutional persons or organizations will be refused. The institution will honor your
request to withhold Directory Information, but cannot assume responsibility to contact you for subsequent permission to release information. For
example, if you request that UIS withhold information, your name will not appear in any printed programs or be released to any newspapers.
Regardless of the effect upon you, the institution assumes no liability for honoring your instructions that information be withheld.
Please sign and date the form below if you do not wish to have Directory Information disclosed. By signing below, you are acknowledging the fact
that you have read and understand the terms of non-disclosure described above. This non-disclosure will remain in effect until you provide written
notice to the Office of Records and Registration to inactivate the non-disclosure.
This form should be submitted to the Office of Records and Registration prior to the tenth class day of the semester (fifth day of the summer
term).
Copy (distributed by the Office of Records and Registration):
Original:
Student
Permanent File
