CNED/CSP Request for Completion of Forms
Consent to Disclose Information Statement: Completion and submission of this form is consent by requestor (student or alumni) authorizing WIU Department of Counselor Education & College Student Personnel to release non-directory information from his/her education record. For each request, this form and any attachment should be completed by requestor first before we can process. DO NOT SUBMIT YOUR SOCIAL SECURITY NUMBER ON YOUR FORM.
Name
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example@example.com
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Street Address Line 2
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Upon completion of the form, please indicate if you would like the form to be
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What kind of form are you uploading
Iowa School Licensure
Illinois School Licensure
Iowa CMHC Licensure
Illinois CMHC Licensure
Other State Licensure
Certificate of Education
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