Release of Information Form

"*" indicates required fields

Student Name*

First Last

CSU ID*

Date of Birth*

Phone

I give permission to Student Conduct Services to release information by verbal or written communication with:

Name/Agency*

If you are filling out this form to authorize your discipline history to be shared with an external study abroad program. Then you will need to include an email and contact person of that program for your request to be processed promptly.

Relationship*

Phone

Fax

Mailing Address

Street Address Address Line 2 City State ZIP Code

Check here to give permission to Student Conduct Services to release all information maintained in my student conduct record.

Otherwise, please indicate the information that you are authorizing for release

Contact the SRC

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