REQUEST TO WITHHOLD DIRECTORY INFORMATION
(Completed form, with signature, must be mailed, faxed, or delivered to the Office of Registration & Records, Bowling Green State
University, Bowling Green, OH 43403. Phone: 419-372-8441. Fax: 419-372-7977.)
In conformance with the Family Educational Rights and Privacy Act of 1974 (Buckley Amendment).
Note: The information items (directory information) listed below may be released to anyone making an inquiry. Filing this
form precludes the University from providing the listed items to anyone—including your insurance company/ies, lending
institutions, etc.—without your express written consent as provided by law and by the Student Code of Conduct.
Once filed, this form remains valid until a new form is received revoking the withhold request.
Please consider:
None of the items will be released verbally or in printed form (e.g., campus telephone directory) except as
provided by law and by the Student Code of Conduct.
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WITHHOLD directory information. (To request that the University withhold the information items
below, except as provided by law and by the Student Code of Conduct, please check the box at the left.)
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DIRECTORY INFORMATION
Student’s name, local address, local telephone number, and e-mail address
Student’s home address and home telephone number
Parent(s)’ name, address, and telephone number
Date and place of birth
Major field of study
Class standing
Participation in officially recognized sports and activities
Weight and height (athletes)
Dates of attendance at Bowling Green State University
Degrees and awards received
The most recent previous educational institution attended
Enrollment status (full/part time, major, year, etc.)
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REVOKE previous request. (To revoke a previous withhold request, please check the box at the left.)
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BGSU ID
Academic Year
Student Name (Please type or print)
Signature
Date
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If you wish to exercise your rights respecting directory information, this form must be complete and on file in the Office
of Registration and Records, 110 Administration Building, Bowling Green State University, Bowling Green, OH 43403.
If you wish directory information withheld from the printed campus telephone directory, this form must be on file by
September 1 of the academic year enrolled.
