Authorization To Disclose Information In Education Records Pursuant To Ferpa printable pdf download

Name: _______________________________________ Date:_________________ UTC ID: ___________

Authorization to Disclose Information

in Education Records Pursuant to FERPA

The University of Tennessee at Chattanooga

UTC Records Office, 109 Race Hall

615 McCallie Avenue, Dept. 5155

Chattanooga, TN 37403

To be reviewed and completed by the STUDENT:

I understand that my education records are protected by the Family Education Rights and Privacy

Act of 1974, and they may not be disclosed without my consent. I hereby authorize the University of

Tennessee at Chattanooga faculty members teaching courses in which I am currently (or was)

enrolled and the Offices of the Bursar, Financial Aid, Records, and Student Development to release

any personally identifiable information from my education records to the individuals designated

below.

Name: ____________________________________

Email Address: _____________________________

Mailing Address: ____________________________

City/State/Zip: ______________________________

Telephone: _________________________________

Once this request is processed, the individuals listed above will be sent an email with the appropriate

PIN to be used when requesting information on this student. If an email address is not provided, a

formal letter will be mailed. UTC email is the official method of communication with students.

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To be completed by the STUDENT in the presence of a NOTARY:

The above information will be released with my FULL CONSENT. I understand that this authorization

remains in effect from today through ___________ (month/day/year). Written notification is required

to revoke this authorization prior to the expiration date indicated above.

Print Name: _____________________________________

UTC ID: ______________________________

Student Signature: _______________________________

Date: ________________________________

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To be completed by NOTARY:

Subscribed and sworn to before me this _______ day of _______________, 20____.

Notary Public: _____________________________________

My Commission Expires: _______________________________

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Return completed ORIGINAL form to the UTC Records Office.

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To be completed by the STUDENT to REVOKE previous authorization:

I, ________________________________ (full name), hereby revoke the Authorization to Disclose previously

submitted to the UTC Records Office.

Student Signature: ________________________________

Date: ________________________________

Authorization To Disclose Information In Education Records Pursuant To Ferpa