This required form serves as an authorization to release information for requests for student records from the Registrar.

Instructions

Please complete all fields and submit to the Registrar, Terra Collins by fax at 217-545-5538, email at tcollins81@siumed.edu or by mail at:

Terra Collins, Registrar
SIU-SOM, Office of Student Affairs
P.O. Box 19624
Springfield, IL 62794-9624

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