Registrar’s Office


I, ________________________________, hereby authorize _________________________________
(Student Name – please print) (Name of office or entity which is custodian of record)

to disclose, make accessible, and furnish the following information:

__ Official Transcript (Registrar)
__ Current Term Grades Only - Includes Overall GPA (Registrar)
__ Contents of Registrar’s Office File (Registrar)
__ Overall and term GPAs (Registrar)
__ Attendance Information as Observed by ______________________(faculty member)
__ Academic Performance as Observed by ______________________(faculty member)
__ Advising Information Held by ________________________________(advisor name)
__ Judicial Affairs File(s) of the School (Student Affairs)
__ Student Accounts Information (Student Receivables)
__ Departmental File(s) ____________________________________(name of department)
__ Residence Life File(s) (Student Affairs)
__ Faculty Recommendation Including g.p.a. and Academic Performance
__ Other: - Description ___________________________________

TO: ________________________________________________________



(Name & address or fax number of person or entity to whom records are to be released)

These records will be used for the sole purpose of: ______________________________________.

This release shall be effective until ________________________ unless revoked by me in writing.

________________________________ _____________________________
(Student ID Number – print clearly)
(Student Name Printed)

________________________________ _____________________________
(Student Signature)