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Get Permission To Release Education Record Information - Purdue

(Recipient): FIRST NAME LAST NAME STUDENT IDENTIFICATI ON NUMB ER ORGANIZATION/SCHOOL DATE ADDRESS E-MAIL ADDRESS CITY, STATE, ZIP FIRST NAME Education record information to be released: Purpose of release: I give permission for to release the specified information to the recipient listed above. STUDENT SIGNATURE DATE OFFICE USE ONLY Action taken: DATE Completed Filed Held Other: BY WHOM.

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