STUDENT INFORMATION RELEASE REQUEST

Student’s Printed Name: _____________________________________________________________

Date Information Required:    ____________________ (DO NOT PUT ASAP!)

Information to be released:

Transcript

Enrollment Status/Dates for:  term_______________          year ________

(e.g., full or part time, dates of enrollment)

Graduation Status (e.g., statement that graduation expected on a certain date provided requirements completed.)

__________________________________________________________________________

__________________________________________________________________________

Self Review of Records (You will be notified of the time and place for review. Skip to the signature.)

Information released to (Include full name, title, address)

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Purpose of Release:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I authorize release of the information as indicated on this form.

_____________________________________________________          ___________________

Signature                                                                                          Date