The execution of this form does not authorize the release of any information other than that specifically described below.

To Whom it May Concern,

I, authorize The Physiological Sciences Graduate Program at The University of Arizona to release:

my University of Arizona transcript only -OR- the following specific information/records: A11 College and University Transcripts copies of standardized test scores, and letters of recommendation

...to the person and/or agency of the Physiological Sciences Recruiting Committee.

Specific purpose of this Authorization:
to evaluate academic record for purpose of recruiting

I understand that some of my records may be protected under the Family Educational Rights and Privacy Act of 1974 and cannot be released without my written permission. I hereby waive all provisions of law and privilege relating to the records described in this disclosure. I certify that this consent has been given freely and voluntarily. I may revoke this consent at any time by providing written notice of such revocation to the University office or person who maintains records of this authorization. This authorization is good for one year from the date I sign this release and photocopies of this release fom1 may be accepted. when presented in person with appropriate identification. I may change the expiration date, if I so desire, by providing written notice to the person or office who maintains a record of this authorization. The person and/or agency receiving this information may not disclose the information received as a result of this disclosure unless specifically authorized in the "purpose" section of this release. The information must be destroyed when no longer needed for the specified purpose.