FERPA CONSENT TO RELEASE STUDENT INFORMATION

TO: __________________________________________________________________ (Name of North Carolina State University representative)

I hereby consent to public disclosure of the education records listed below (e.g. tests, graded submissions, transcripts, etc.):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I desire for my education records listed above to be released to the following persons:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

The purpose of this consent is to: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

This consent will expire: ____________________________________________

Name (print)_____________________________

Signature________________________________

Student ID Number________________________

Date_____________________________________