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Authorization to Release Non-Directory Information

MISSOURI SOUTHERN STATE UNIVERSITY
OFFICE OF THE REGISTRAR


I hereby authorize Missouri Southern State University to release all educational records.

RELEASE TO:
*Name: 
*Address: 
*City: 
*State:
*Zip: 

*Student Name: 
*Student ID Number: 
This consent will remain in effect from the date of submission until the Office of the Registrar receives written authorization to remove it as long as the student is enrolled at MSSU.

THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMATS UPON REQUEST. IF YOU NEED ASSISTANCE, PLEASE CONTACT THE REGISTRAR'S OFFICE at (417)625-9515.
The following information will constitute as an electronic signature.
*Student E-Signature: 
*Today's Date: 
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