Enrollment Services - Directory Information Restriction Form

Directory Information Restriction Form

Check off which category(ies) of information you would like witheld. The information categories checked off will be restricted. This will be effective for one academic year.

Name (First MI Last):
Email Address:
SSN or SID:	(123-45-6789)
Career Level:

		Name			Dates of Attendance
		Local Address			Major
		Permanent Address			Classification
		Address for Mail Lists			Degrees Awarded
		Telephone Number			Honors
		Sex			Awards
		Race			Class Standing
		Nationality			Previous Institution Attended
		Date of Birth			Photograph
		Place of Birth			Weight/Height of Athlete
		Parents' Name			Sports Participation
		Parents' Address			Parking Permit Information
		Class Schedule			Judicial Information

Statement of Responsibility

I understand that the above information will be witheld from inquiries with the exception of those stated in the Accessibility of Educational Records for the current academic year. This request, if desired, must be renewed each academic year.

I understand the above statement of responsibility:

Date (MM-DD-YYYY):

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