Penn State Office of the University Registrar

Request to Withhold Directory Information

Please fill out this online form, print (using "Print Form" button at bottom of page), sign and:
Return to:
Registrar's Office
112 Shields Building
University Park, PA 16802

The following items of information regarding a student's record are considered directory information. Directory information is considered as public information and may be released without the student's prior consent.

  1. Name
  2. Address (local, permanent residence and electronic mail)
  3. Telephone number
  4. Class level (semester class or level: first-year, sophomore, junior, senior, etc.)
  5. Major
  6. Student activities
  7. Weight/height (athletic teams)
  8. Dates of attendance
  9. Enrollment status (full-time, part-time, or not enrolled)
  10. Date of graduation
  11. Degrees and awards received and where received
  12. Most recent educational institution attended

Filing this form will preclude the University from releasing directory information to anyone (including yourself) without express written consent. To process this request you must present this form along with photo identification to any campus Registrar's office or mail this form along with a copy of photo identification to the address listed above

I have read this form carefully and understand the consequences of my decision to prevent release directory information. I understand:

Please review your entries on this form. If all of the information is entered correctly, please print (using "Print Form" button at bottom), sign and submit the form to the address at the top.

Signature: _____________________________________ Date: ___________________

Address where you may be reached:

Office Use Only

Received By: _____________________________________ Date Received: ___________________

Revised 3/1/11