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Faculty Handbook - Fairmont State University

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AUTHORITY TO RELEASE PERSONALLY IDENTIFIABLE<br />

INFORMATION FROM EDUCATION RECORDS<br />

43<br />

Pursuant to the Family Educational Rights and Privacy Act of 1974, as amended,<br />

I,_________________________________________________________________, 1 give my consent to authorized<br />

representatives of <strong>Fairmont</strong> <strong>State</strong> <strong>University</strong> for the release of my educational records and<br />

any and all personally identifiable information contained therein, including educational<br />

information, employment information, and information contained in the records of FSU’s<br />

Student Affairs Office to<br />

__________________________________________________________________________________________________________ 2<br />

for purpose of_________________________________________________________________________________________<br />

__________________________________________________________________________________________________________ 3<br />

_________________________<br />

(Date)<br />

_____________________________________________________________<br />

(Signature)<br />

___________________________________________________________<br />

(Student Identification Number)<br />

NOTE: If an FSU student so requests, FSU shall provide him or her with a copy of the records<br />

disclosed.<br />

________________________<br />

1 Name of FSU student.<br />

2 Identification of party or class of parties to whom the disclosure may be made.<br />

3 Purpose of disclosure.

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