Third-Party Authorization Form (TPAF)
Overview
Purdue Global students may authorize the release of non-directory, personal information to another individual(s) by submitting this Third-Party
Authorization Form. Third-Party Authorization does not act as, or take the place of Power of Attorney. In addition, Purdue Global reserves the right
to revoke the Third-Party Authorization at any time.
Instructions
To grant access to your information to designated individual(s) or to revoke previously-granted access, complete this form.. Note that authorized
parties will be required to verify their identity when speaking to Purdue Global sta about your records by providing their name, their relationship
to you, their phone number, and the last 4 digits of your SSN. Be advised that processing this form may take up to 6-8 business days from the date
of receipt. Incomplete forms will not be processed.
To complete this form, input all required information and electronically initial and sign where required. When the form is complete, click Finish
to submit it to the University. Please ll out the form completely and accurately to avoid potential delays in processing.
If you are unable to electronically initial and sign the form, or have any questions, please contact your Student Support Specialist toll free at 866-
522-7747 for assistance.
Student Information
STUDENT NAME: ______________________________________ PURDUE GLOBAL STUDENT ID OR LAST 4 DIGITS OF SSN: __________________
EMAIL ADDRESS: ______________________________________ STUDENT SUPPORT SPECIALIST OPTIONAL: ____________________________
REASON FOR RELEASE OF INFORMATION: ______________________________________________________________________________________
Third Party
Third Party
Place an X in ONE of the columns
below for each individual listed.
First and Last Name of Contact Relationship to Student Phone Number
I grant this person
access to my
records.
I withdraw
permission for
this person
to access my
records.
I choose to share the following types of records with authorized individual(s) (check only ONE):
__ ALL RECORDS ___ ACADEMIC RECORDS ONLY ___ FINANCIAL RECORDS ONLY
THIS AUTHORIZATION IS VALID UNTIL SPECIFIC EXPIRATION DAY, MONTH, AND YEAR REQUIRED: _______________________
I authorize and/or withdraw, as noted above, permission for the above individual(s) indicated to access my student record. My information may
be released to any person(s) granted access above from this date until the expiration date specied above, unless revoked earlier by me via
submission of an additional Third-Party Authorization form. I acknowledge that this Third-Party Authorization form allows permission for Purdue
Global to share information only; it does not allow the above authorized parties to make decisions my behalf. I acknowledge that Purdue Global
may revoke third-party authorization at any time.
Student Signature: ______________________________________________________________ Date: __________________________________
PARTY AUTH 2223 REV 08/2018
OFFICE OF THE REGISTRAR
550 West Van Buren Street
Chicago, IL 60607
Tel: 866-522-7747
Fax: 800-588-4127 (Toll Free)
