Privacy Hold/Information Release

Student ID or SSN Number
Must be 10 digits. Currently Entered: 0 digits.
Name Name First Last
Phone Phone - ### - ### ####
Current Mailing Address Current Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
By checking this box I am asking that no information be released without proper identification.

By checking this box I am asking that no information be released without proper identification. I agree
Draw your signature into the box below.

Draw or Type

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Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY