Nondisclosure Form - Cisco College printable pdf download

REQUEST TO PREVENT DISCLOSURE OF DIRECTORY INFORMATION

The items listed under Directory Information may be released in accordance with the Family Educational Rights and Privacy Act of 1974

(FERPA), as amended. Under the provisions of FERPA, as amended, you have the right to withhold the disclosure of Directory Information. Please

consider carefully the consequences of any decision to withhold Directory Information. Should you decide to inform this institution not to release

Directory Information, any future request for such information from non-institutional persons or organizations will be refused. For example, the

college would be unable to verify degree, major or enrollment for possible employment, credit card applications, insurance purposes, mortgage

information, apartment leases, etc.

Should you decided to withhold Directory Information, you may authorize at a later date on a transaction-by-transaction basis the release of

directory or non-directory information (for example, the release of a transcript for employment purposes) or you may cancel withhold directory. See

below for instructions.

Note to students about to graduate: The withhold directory flag will remain on your records after graduation if you have requested that the

information be withheld; therefore, we will not be able to verify your degree to potential employers. (See below for removal of Withhold Directory

Information designation.)

Cisco College will honor your request to withhold the information listed below, but cannot assume responsibility to contact you for

subsequent permission to release that information. Regardless of the effect upon you, Cisco College assumes no liability for honoring your request

for information to be withheld.

Directory Information includes the following:



Student’s full name



Addresses-local, permanent and e-mail



Telephone listings, both local and permanent



Date of birth



Major field of study



Participation in officially recognized activities and sports



Photographs



Weight and height of members of athletic teams



Dates of attendance



Degrees and awards received



Most recent previous school attended



Classification



Enrollment status

This form should be submitted to the Registrar’s Office on or before the 12

class day of the spring or fall semester, the 4

class day of the

summer term, or the first class day of mini-mester terms. Forms will be accepted after these deadlines, but we cannot be responsible for the release

of Directory Information prior to receiving the Directory Information Withhold request in the Registrar’s Office.

Directory Information Withhold/Release Form

Withhold Directory Information

Release Directory Information

I want Directory Information to be withheld. (Directory Information

I want Directory Information to be released. (Directory Information

includes all items listed above.) I wish to prevent the disclosure of

includes all items listed above.) I no longer wish to prevent the

my Directory Information and understand the ramifications of doing

disclosure of my Directory Information and release Cisco College

so.

from any responsibility to withhold open Directory Information from

the date this form is received in the Registrar’s Office.

Name (print)________________________________________

Social Security Number_______________________________

Signature__________________________________________

Date______________________________________________

From the date this form is received in the Registrar’s Office, we will

honor your request to withhold directory information until you

request in writing that you wish to remove the withhold directory

honor your request to Release Directory Information.

Return this form to: Cisco College, Registrar’s Office

information designation. You may authorize the release of

information in writing on a transaction-by-transaction basis without

101 College Heights

removing the withhold directory designation (see above).

Cisco, Texas 76437

Nondisclosure Form - Cisco College

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