COMMITTED TO STUDENT SUCCESS
RECORDS CENTER REQUEST
The following information is required to assist in locating the requested record. Please complete and return this form to the above address.
*** Please note that to process a request
the Records Center will have 3 business days to respond***
Please print full name (include maiden/others) as used
in school:
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Last Name |
First Name |
Middle Name |
Maiden or Other |
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Educational Verification:
Date of Graduation: Name of High School: Date of
Withdrawal: School Attended:
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Employment Verification:
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Location: |
Year(s) of Employment: |
Date of Birth: Date of Request:
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Month |
Date |
Year |
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Month |
Date |
Year |
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Student/Parent: A processing
fee of $3.00 must be received on the
date of the request for each official copy of a student’s transcript(s)/record(s). (Cash/Money
Order/Cashiers Check only) No personal
checks.
Business/Agency: A processing
fee of $5.00 must be received on the
date of the request for educational verification and/or employment
verification. (Business Check/Money Order/Cashiers Check only)
Number of copies requested: ____________
Please provide name, address, and telephone # of the agency/person to receive the requested records.
(1) (2)
______________________________________ _____________________________________
______________________________________ _____________________________________
______________________________________ _____________________________________
Must present proof of
identification: Picture ID (Driver’s License, Employment ID Badge, Passport, State
ID)
(Attach a copy of your ID when mailing this request).
Signature of authorized person (student if 18 or older), otherwise parent/guardian:
_________________________________
Name of the authorizing person (print): __________________________________________________________
Telephone number of the authorizing person (include area code): _________________________________________
Current mailing address of the authorizing person: ___________________________________________________
Street
/ P.O. Box City State Zip Code
DO NOT WRITE BELOW THIS LINE.
FOR RECORDS
CENTER USE ONLY
Proof of Identification: Driver’s License ________ (attach copy) State ID ___________ (attach copy)
Employment ID ________ (attach copy) Passport ___________ (attach copy)
Carried by Hand: _______________ Fax
to: ________________ Mailed to:
_______________________
Date: ________________ Date:
_________________ Date:
_________________
Amount Paid: $______ ( ) Cash ( )
Money Order ( ) Cashiers/Business Check ( )
Fee exemption (government / state /educational institute)