Fillable AUTHORIZATION FOR RELEASE OF INFORMATION (Louisiana Tech University)

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AUTHORIZATION FOR RELEASE OF INFORMATION (Louisiana Tech University)

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AUTHORIZATION FOR RELEASE OF INFORMATION
Name ____________________________________________ SS# __________________
(Please Print) Last First Middle
Classification ______________________________________ Major ________________
I am requesting the following information:
=====================================================================
_____ Enrollment Verification for: ____ Health Insurance ____ Loan
____ Fall ____ Winter ____ Spring ____Summer
_____ History of Enrollment: (Includes all dates of attendance)
Letter will include the following:
• Full, half, or part-time enrollment status
• Anticipated date of graduation
=====================================================================
____ Letter for “Good Student Discount” (auto insurance)
• Student must have a GPA of 3.000 or better
=====================================================================
____ Letter of academic standing to be mailed to another school:
School & Address _______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
• Student must be in good academic standing
=====================================================================
____ I would like the information faxed or mailed to:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____ I will pick up the information requested
________________________________________________________________________
Signature of Student Required Date of Request
2/2002-REGISTRAR-BD
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Completed 23 July 2020

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