Microsoft Word - rec_release_ref

Rev. 04/18 – Records | rec_release_ref_let.doc

Office of the Registrar

503-725-3220

503-725-5525 fax

www.pdx.edu/registration

STUDENT CONSENT FOR

LETTERS OF RECOMMENDATION

The Portland State University Records Policy, in compliance with the Family Educational Rights and Privacy

Act of 1974 (FERPA), requires the written consent of the student authorizing the disclosure of non-directory

information from his or her record. The authorization must include: the specific information to be released;

the party or class of parties to whom the information is to be released; the purpose of the release; the date;

and the student’s signature.

I am requesting a one-time only release of information to the following party/ class of parties for the

following purpose.

I, ______________________________________________, Student ID ________________________,

(please print your name clearly)

hereby give my written consent to

(name of PSU faculty or staff member)

to disclose the following information:

(specify records/information to be released: GPA, grades, academic performance, class attendance, etc.)

I authorize PSU to release the above-mentioned education records, for the purpose of providing a

letter of recommendation, to:

(specify person/s to whom release be made)

I understand that the specific information referenced on this form is being released to a third party at my

request with the understanding that s/he will not release it to any other parties. Portland State University is

hereby released from all legal responsibility or liability for the release of the above-mentioned information.

Student Signature Date

Portland State University is required to keep original signed consent forms.

Students are advised to keep a copy of this form with their records.

Receipt date_______ Staff Initials _______

Please bring your

Photo ID when

submitting

this form