Consent To Release Personal Information - Arkansas


Consent to Release Personal Information
Enter the name(s) of the individual(s) with whom you authorize ADHE to discuss
your personal information. Do not enter an organization, such as “UALR”, or
generic identification, such as “my parents”, or Mr. and Mrs. Smith.”
I, _______________________, hereby give permission for the Arkansas
Department of Higher Education to discuss my personal information with
____________________________. I understand that I am foregoing my privacy
rights with regards to any and all information that ADHE has to any and all
individuals named in this release.
Student Name:________________________________________________
Last 4 of Student SSN:_________________________________________
Student Signature:_____________________________________________
Send the completed form to the Arkansas Department of Higher Education using
one of the following methods:
Fax: 501-371-2001 (Attn: Financial Aid)
E-mail: Scan the completed form to a pdf document and e-mail that document to
(Subject: Consent Form)
Mail: Arkansas Department of Higher Education
Attn: Financial Aid
423 Main Street, Suite 400
Little Rock, AR 72201


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