Student Portal Account Release Form
Please complete all fields to request the release of your student portal account. All information is required to process your request efficiently.
Full Name
*
First Name
Last Name
Student ID Number
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Account Release Request
*
Permanent Account Closure
Temporary Suspension
Password Reset Only
Other
Reason for Account Release
*
Preferred Contact Method
*
Email
Phone
Date of Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supporting Document (if applicable)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Request
Submit Request
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