Office of the Bursar, William Paterson University, College Hall, PO Box 913, Wayne, NJ 07474-0913

Family Educational Rights and Privacy Act
Permission to Release Information
In compliance with the Federal Family Educational Rights and Privacy Act of 1974 as amended (FERPA), information about your student fee account may NOT be released to a third party (i.e. your parents, spouse, sponsor, etc.) without your written permission. To grant specific individuals access to your student account information, please complete this form.

I, _______________________________________, authorize the release of information on my
                           Print Name (first/middle/last)

student account(s) with the Office of the Bursar at William Paterson University to the individual(s) listed
below. This permission is valid until ___________________________ (expected date of graduation).
                                                                           Month/Year

Name                                                                             Relationship

_________________________________________________________________________

Name                                                                             Relationship

_________________________________________________________________________

Please note: This authorization pertains to student fee account inquiries only.
Requests for information maintained by other offices (i.e. Office of the Registrar, Office of Student Financial Aid, Housing, etc.) are not covered by this authorization.

_______________________________               _______________________________
                 Student ID Number                                                        Student's Signature