I-20 Third Party Release Form

I-20 Third Party Release Form
This form should be used by students who are authorizing a third party to pick-up Form I-20 documents.
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Student’s last name (surname)
____________________________
Student’s first name (given name)
_______________________________
E-mail Address
_____________________________
UH (PeopleSoft) ID
_______________________
Date of birth (mm/dd/yyyy)
Individual Authorized to Pick-up I-20:
___________________________________
Last name
_______________________________
First name
___________________________________
Relationship to student
_______________________________
Contact phone number
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I, __________________________________, hereby authorize that ____________________________
has been granted permission to retrieve all Form I‐20 documents on my behalf from the University of Houston
Graduate School. I understand that the above-named person is required to show proof of picture identification
when picking up my document(s). I understand that once these documents are released to my designee, he/she
takes full responsibility in making arrangements to deliver these documents to me. I further understand that should I
need to appoint an alternate designee, I will immediately notify the University.
________________________________________
Student’s signature
__________________________________
Date of signature (mm/dd/yyyy)