Name

Ten Digit University ID Number

I hereby request the IUPUI Registrar's Office to remove the RESTRAINT OF STUDENT INFORMATION RELEASE FORM that I filed with that office ____________(date).

I understand (1) that all public information, limited to:

• Name
• Address
• 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

will be released freely, and (2) that a copy of this REMOVAL form will be forwarded to my school or division and to other university offices that maintain student records.

_____________________________________________
Signature

_____________________________________________
Date

_____________________________________________
School/Division