Release of Student Records Form

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Under the provisions of the Family Education Rights and Privacy Act (FERPA), I authorize Student. Records to release and
Financial Aid and Student Records Student Wing, Room 119 PO Box 6000 Binghamton, New York 13902-6000

Phone: 607-777-6088 Fax: 607-777-6515 Email: [email protected] www.registrar.binghamton.edu

RELEASE OF STUDENT RECORDS Under the provisions of the Family Education Rights and Privacy Act (FERPA), I authorize Student Records to release and/or discuss the following records and information about me from my educational file.

Grades

Schedules

Credit Hours

Holds

Graduation Status

Other

Name of person who has permission to receive the information: Full Name:_____________________________________ Email:______________________________ Relation/Affiliation to student:_____________________ Phone:______________________________ Purpose for releasing student record: ________________________________________________________________________________ ________________________________________________________________________________

I agree to the release until the following date:________________ .

Printed Name

B-Number

Student Signature

Date

Must be submitted in person by student to Student Records. Please allow 3-5 business days for processing before requesting information.

06172011 EMM