Disciplinary Records Release Form

Requestor's Information

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Student Information

Student's name

RUID Number

Recipient Information

List the name, address, email address, and phone number of each individual or organization to whom disciplinary records should be provided.

Recipient #1 Name, address, email address, and phone(Required) This field is required.

Recipient #2 Name, address, email address, and phone This field is required.

Recipient #3 Name, address, email address, and phone This field is required.

These records will be used for the purpose of:(Required) This field is required.

This release shall be effective until ________ unless revoked in writing by me.(Required)

This field is required.

Initial here and upload a photo of your signature in the "Supporting Documentation" section below.(Required) This field is required.

Supporting Documentation

Upload a photo of your signature here. If you have a form for the Office of Community Standards and Student Development to complete, such as a "Dean's Letter" or "Dean's Certification" form, upload it here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Disciplinary Records Release Form - Newark

Requestor's Information

Student Information

Recipient Information

Supporting Documentation

Submission