Form 3/2012 - Authorization To Release Information Form
Download a blank fillable Form 3/2012 - Authorization To Release Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 3/2012 - Authorization To Release Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Financial Aid & Scholarship Department
Division of Student Affairs
Bayramian Hall, Student Services Center
18111 Nordhoff Street, Northridge, CA 91330-8307
Phone: (818) 677-4085
AUTHORIZATION TO RELEASE INFORMATION
Forms not submitted in person to a Financial Aid Staff member must be notarized.
2011-2012 Academic Year
OR
2012-13 Academic Year
____ I understand that this form is ONLY in effect with the Financial Aid & Scholarship Department at CSUN.
Initials
____ Authorization is in effect until I request, in writing, that it be rescinded or until the end of the academic year
in which it was issued, whichever comes first; and in the event information is released by mistake, the
Initials
undersigned agrees to hold CSU, Northridge harmless for damages.
____ I authorize the CSUN Financial Aid Staff to disclose my Financial Aid information to the party identified
below. Financial Aid information may include Financial Aid, Scholarship, Admissions, Records, and Student
Initials
Accounting information.
Complete this section if you are the STUDENT authorizing CSUN to release your information to
another person.
I, the student, authorize CSUN to release information from my University Records to the following person:
Name:__________________________________________ Relationship:______________________
Last 4-digits of social security number and place of birth:___________________________________
Student’s Name:___________________________________
Student ID:__________________
Student Signature:_________________________________
Date:______________________
Complete this section ONLY if you are the PARENT of a CSUN student, authorizing CSUN to release
your information to another person (including your student).
I, the parent of a CSUN student, authorize CSUN to release PARENT information from my University
Records to the following person:
Name:_______________________________
Relationship to Parent:____________________
Last 4-digits of social security number and place of birth:___________________________________
If authorization is to a CSUN student, provide the Student ID:________________________
Parent’s Name:___________________________________ Driver’s License #:__________________
Parent Signature:_________________________________
Date:______________________
For Office Use Only:
Authorization Coded: ________________
Authorization Terminated:_________________
Date
Date
Checked ID?
Yes
No
Notarized:
Yes
No
Authorization to Release Information Form 3/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal