Request to Withhold Directory Information

Please print, sign, and return the completed form to:

Office of the University Registrar
112 Shields Building
University Park, PA 16802

Please print, sign, and return the completed form to:
Office of the University Registrar
112 Shields Building
University Park, PA 16802

NOTE: Students with access to LionPATH should complete and submit a request to withhold directory information using the Change Directory Info (FERPA) form in LionPATH.

The following items of information regarding a student's record are considered directory information. Directory information is considered as public information and may be released without the student's prior consent.

Name
Address (local, permanent residence and electronic mail)
Telephone number
Class level (semester class or level: first-year, sophomore, junior, senior, etc.)
Major
Student activities
Weight/height (athletic teams)
Dates of attendance
Enrollment status (full-time, part-time, or not enrolled)
Date of graduation
Degrees and awards received and where received
Most recent educational institution attended

Filing this form will preclude the University from releasing directory information to anyone (including yourself) without express written consent. To process this request you must present this form along with photo identification to any campus Registrar's office or mail this form along with a copy of photo identification to the address listed above.

I have read this form carefully and understand the consequences of my decision to prevent release directory information. I understand:

this prohibits Penn State from acknowledging any information regarding my enrollment to any third party including employers, loan deferments, requests from non-institutional persons/organizations, or me unless a written request with my signature is received. No information will be released to me or any person(s) via the telephone or email.
this does not prevent disclosure to personnel within the University or a lawfully issued subpoena.
this suppresses my information verbally and in printed form (i.e. campus directory, Web directory, Commencement Program).
that this is applicable until such time as I request that it be removed, that I must initiate this option by filing a request to "Release Directory information" with photo identification.

Authorization

Today's Date

Please enter today's date.

Student Name

Please enter your name.

PSU ID 9-digit Penn State ID number

Please enter your PSU ID.

Phone Number Please include area code

Please enter your phone number.

Please enter a valid email address.

Current/Previous Campus

Please enter your current or previous campus.

Date(s) of Attendance

Please enter your dates of attendance.

Please review your entries on this form. If all information is entered correctly, please print, sign, and submit the form to the address at the top.

Student Signature

Student Signature: _________________________________

Date: ____________________________

Student Signature: _______________________________________ Date: __________________________

Address Where You May Be Reached

Street Address 1

Please enter your street address.

Street Address 2

City

Please enter your city.

State

Zip Code

Please enter your zip code.

Office Use Only

Received by: ___________________________________________________

Date Received: ____________________________

Last Revised: 3/1/11