IUPUI Rescind Prior Consent Form
|
| Name
_____________________________________________________ |
| Ten Digit Student Identification
Number ___________________________ |
| Date
______________________________________________________ |
|
| Rescind Consent: |
|
I hereby rescind the prior consent granted to
__________________________________________ (School,
department or individual’s name) to release and/or discuss
private student academic record information with the individual listed
below. |
| Authorization Previously Granted To: |
| Name of Individual
_____________________________________________________ |
| Relationship to Student
__________________________________________________ |
|
| |
| Student Signature _____________________________
Date_________________ |
