Southeast Missouri State University

Southeast Missouri State University

Office of the Registrar Mail or Fax this Form to: Southeast Missouri State University Office of the Registrar One University Plaza, MS 3760 Cape Girar...

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Office of the Registrar Mail or Fax this Form to: Southeast Missouri State University Office of the Registrar One University Plaza, MS 3760 Cape Girardeau, MO 63701 Office: 573-651-2250 Fax: 573-651-5155

Permission to Release Confidential Information This form has been provided for students who wish to allow an individual or agency to obtain confidential information. Information may be obtained by the specified individual or agency by sending a written request to the Registrar’s Office. There will be a two day processing time upon receipt of the request.

Student’s Name: _________________________________________________ Southeast ID Number :_____________________________________________ Address: _______________________________________________________ _______________________________________________________ Individual or agency authorized to obtain information: ____________________ ________________________________________________________________ Release is valid from: ________________ to ___________________ mo/day/yr mo/day/yr Type of information to be released (ex: semester grades, hours enrolled, transcript):

________________________________________________________________

SIGNATURE____________________________________ Date _______________ This release is not valid without the student’s signature. *Information will only be released to individuals or agencies listed above.