Removal of the Restraint of Release of Student Information Form

Removal of the Restraint of Release of Student Information

Student Name	________________________________________________________________________ Last First Middle
Ten Digit University ID Number:	_____________________	OR	Last four digits of SSN:	_____________________

I hereby request that the IUPUI Registrar's Office remove the RESTRAINT OF STUDENT INFORMATION RELEASE from my academic record that was previously applied.

I understand that public information, listed below:

Name
Address (though IUPUI does not typically release)
E-mail Address
Major field of study
Dates of attendance
Admission or enrollment status
Campus

School or division
Class standing
Degrees and awards
Activities
Sports and athletic information
Records of arrests and/or convictions
Traffic accident information

may be released freely, and that a copy of this REMOVAL form will be forwarded to my school or division and to other university offices that maintain student records.

I also understand that in order to honor this release, my signature must be notarized before I submit this form.

_____________________________________________
Signature

_____________________________________________
Date

State of ____________________ County of __________________	) )ss. )	Before me, a Notary Public in and for said County and State, personally appeared ____________________________________________, and acknowledged the execution of the foregoing instruments as his/her voluntary act and deed, and who, being first duly sworn upon his/her oath, swears that the statements and representation made herein are true and accurate to the best of his/her knowledge and belief.
WITNESS MY HAND AND NOTARIAL SEAL this ______ day of _______________________, 20___

__________________________________________ County of Residence		__________________________________________ Signature of Notary Public

__________________________________________ My Commission Expires		__________________________________________ Printed

Fax to: 317-278-2240
Mail to: Office of the Registrar Cavanaugh Hall, Room 111 425 University Boulevard Indianapolis, Indiana 46202-5143		Visit us at : Office of the Registrar Campus Center, Suite 250 420 University Boulevard Indianapolis, Indiana 46202-5144