Consent To Release Personal Information - Arkansas printable pdf download

Consent To Release Personal Information - Arkansas

Consent to Release Personal Information

Enter the name(s) of the individual(s) with whom you authorize ADHE to discuss

your personal information. Do not enter an organization, such as “UALR”, or

generic identification, such as “my parents”, or Mr. and Mrs. Smith.”

I, _______________________, hereby give permission for the Arkansas

Department of Higher Education to discuss my personal information with

____________________________. I understand that I am foregoing my privacy

rights with regards to any and all information that ADHE has to any and all

individuals named in this release.

Student Name:________________________________________________

Last 4 of Student SSN:_________________________________________

Student Signature:_____________________________________________

Date:________________________________________________________

Send the completed form to the Arkansas Department of Higher Education using

one of the following methods:

Fax: 501-371-2001 (Attn: Financial Aid)

E-mail: Scan the completed form to a pdf document and e-mail that document to

finaid@adhe.edu

(Subject: Consent Form)

Mail: Arkansas Department of Higher Education

Attn: Financial Aid

423 Main Street, Suite 400

Little Rock, AR 72201

Consent To Release Personal Information - Arkansas