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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 specific/other educational records which include records kept by the following offices, if applicable - Mental Health/Counseling records, Health Center records, Disability Accommodation Services, Project Stay, Athletics Department, Veteran Services, MKEAP, Honors Program, Global Leaders, MOSO CAPS, and other programs you are involved in

List of other records requested: 
List the records you want excluded from the records requested: 
RELEASE TO:
*Name: 
*Address: 
*City: 
*State:
*Zip: 
*Student Name: 
*Student ID Number: 
**This authorization will be effective the date of request until a written letter revoking it is received in the Office of the Registrar.

THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMATS UPON REQUEST. IF YOU NEED ASSISTANCE, PLEASE CONTACT THE REGISTRAR'S OFFICE at phone number (417)625-9515 or email the Registrar Office.
The following information will constitute as an electronic signature.

The username and password are the same as used to log into Lionet.

Username:
(For example, doej001)

Password:
(Pin assigned with your S#)
Username
Password