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: 317-274-8920

Mail to/Visit us at :
Office of the Registrar
Campus Center, Suite 250
420 University Boulevard
Indianapolis, Indiana 46202-5144


Copyright - The Trustees of Indiana University