Confidential Records Release- Education Department

General Information

	Last Name:
	First Name:
	Middle Name:
	Date of Birth (mm/dd/yyyy)
	Graduation date (semester and year)
	Former/Maiden Name:
	Banner ID:

Contact information

	email address:
	phone number:

Intended Licensure Area

Example: Elementary Education, Mid-level Math, K-12 Instrumental Music, etc.

I authorize CSB+SJU to release:

*For Minnesota State Tier 2 and 3 licenses, all documents except ACT are required.

	MN PELSB license application
	Official transcript for licensure and any course substitutions applicable
	Verification of Completion of a State-Approved Licensure program
	Fingerprint card
	ACT scores
	OPI Scores (World Languages only)

These records will be used to:

If needing records released for multiple reasons, please fill out a separate request form for each.

	Obtain teaching license in Minnesota
	Obtain teaching license elsewhere
	Other

Details

If seeking teaching license in another state or needing records for something other than licensure, please provide information here.

Attestation

I give permission to CSB + SJU Education Department to share these documents on my behalf. If I change my mind, I will contact the Education Department Program Coordinator immediately. This release of information is valid for one year from the date submitted.

	Electronic Signature (type full name)
	Date

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