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: ____________________________________
Name: ____________________________________
Email Address: _____________________________
Email Address: _____________________________
Mailing Address: ____________________________
Mailing Address: ____________________________
City/State/Zip: ______________________________
City/State/Zip: ______________________________
Telephone: _________________________________
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.
*******************************************************************************************************************
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: ________________________________
*******************************************************************************************************************
To be completed by NOTARY:
Subscribed and sworn to before me this _______ day of _______________, 20____.
Notary Public: _____________________________________
My Commission Expires: _______________________________
*******************************************************************************************************************
Return completed ORIGINAL form to the UTC Records Office.
*******************************************************************************************************************
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: ________________________________