Authorization to Discuss Specified Educational Records

Under the Family Educational Rights and Privacy Act

By signing this Authorization I, ________________________________, 991 - __ __ __ -__ __ __,

                                                       (print full name)                                             (student id #)

give Indiana State University offices/officials my consent/permission to discuss my undergraduate and/or graduate education records with the person (s) I have listed below. This authorization does not necessarily include provision of copies of the specified records to any party.  I am designating the records that may be discussed by placing a mark on the line next to one or more of the following three categories:

___  Official Academic Records (main contact Office of Registration and Records)

___  Financial Records (main contacts Bursar and Financial Aid Offices)

___  Items that prevent Registration in classes (main contact Office of Registration and Records)

I understand that by giving my consent to allow ISU representative(s) to discuss my education records with the designated person(s), ISU is in compliance with the Family Educational Rights and Privacy Act.  I understand that this Authorization will be in effect this year through October 1 next year, or until I rescind it in writing, whichever occurs first.  Further, I understand that any re-authorizations are my responsibility to initiate.  I will inform the designee(s) below that any information s/he receives may not be transmitted to a third party.

      ___________________________________________________________________

       Designated Representative    (print full name)

      ___________________________________________________________________

       Designated Representative    (print full name)

       __________________________________________________________________

       Designated Representative    (print full name)

I understand that if my designee forgets the code, s/he must contact me, as ISU representatives are not authorized to reveal this code to anyone, even me.  My code is__ __ __ __ __ __.

Please Note:

A code must be assigned by you and given to the designee(s) listed above to enable ISU representatives to verify their identity.  Each designee will use the same code.  The code may be any combination of letters and/or numbers, but it must be six characters.  Please choose something you will remember as you must complete a new form if you forget the code.

This completed form must be brought by the student to the Office of Registration and Records, Parsons Hall,  room 009, along with picture identification, or else it must be submitted via the student's Indstate email account.   In order to rescind this authorization before the auto expiration date, a written request and picture identification must be brought to the Office of Registration and Records. Or, you may request the authorization be rescinded via your Indstate email account.         Last revised 1/27/09