Third-Party Authorization Form (TPAF)

ONLINE
DAVENPORT
Tel: 866.527.5268 (Toll Free)
Tel: 563.355.3500
AUGUSTA
DES MOINES
Tel: 207.213.2500
Tel: 515.727.2100
CEDAR FALLS
HAGERSTOWN
Tel: 319.277.0220
Tel: 301.766.3600
CEDAR RAPIDS
Indianapolis
Tel: 877.320.5430
Tel: 319.363.0481
LEWISTON
OMAHA
Tel: 207.333.3300
Tel: 402.431.6100
LINCOLN
ROCKVILLE
Tel: 402.474.5315
Tel: 301.258.3800
MASON CITY
South Portland
Tel: 641.423.2530
Tel: 563.355.3500
Milwaukee
St. Louis
Tel: 414.223.2105
Tel: 314.205.7900
Third-Party Authorization Form (TPAF)
OVERVIEW
Kaplan University students may authorize the release of non-directory, personal information to another individual(s) by submitting this
Third-Party Authorization Form. Third-Party Authorization does not act as, or take the place of Power of Attorney. In addition, Kaplan
University reserves the right to revoke the Third-Party Authorization at any time.
INSTRUCTIONS
To grant access to your information to designated individual(s) or to revoke previously-granted access, complete the appropriate fields
below, print, sign, date, and submit this form to the appropriate Office of the Registrar. Note that authorized parties will be required to
verify their identity when speaking to Kaplan University staff about your records by providing their name, their relationship to you, their
phone number, and the last 4 digits of your SSN. Be advised that processing this form may take up to 6-8 business days from the date of
receipt. Incomplete forms will not be processed.
• Online and Learning Center students must submit this form via email attachment to [email protected] or
via fax to 1-800-588-4127.
• Campus students must submit this form to their onsite Office of the Registrar.
STUDENT INFORMATION
Student Name: ___________________________________________________ Kaplan Student ID or last 4 digits of SSN: __________________
Email Address: ___________________________________________________ EDUCATION Advisor (optional): _____________________________
Reason for RELEASE of information: _____________________________________________________________________________________
THIRD PARTY
Third Party
Name
(First and last name of contact required)
Place an X in ONE of the columns
below for each individual listed.
Relationship to Student
Phone Number
I grant this person
access to my records.
I withdraw
permission for this
person to access my
records.
I choose to share the following types of records with authorized individual(s) (check only ONE):
___ All Records
___ Academic Records Only
___ Financial Records Only
This authorization is valid until (specific expiration day, month, and year required): __________________
I authorize and/or withdraw, as noted above, permission for the above individual(s) indicated to access my student record. My information
may be released to any person(s) granted access above from this date until the expiration date specified above, unless revoked earlier
by me via submission of an additional Third-Party Authorization form. I acknowledge that this Third-Party Authorization form allows
permission for Kaplan University to share information only; it does not allow the above authorized parties to make decisions my behalf.
I acknowledge that Kaplan University may revoke third-party authorization at any time.
___________________________________________________________
________________________________________________
Student Signature Date
party auth - 2223 Rev 10/2013