Verification Request Form
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1SHEPHERD UNIVERSITY
Verification Request Form
Updated 10/12
3200 N. San Fernando Rd., Los Angeles, CA 90065 Tel: (323) 550-8888 Fax: (323) 550-1313
FIRST
MIDDLE
LAST
OTHER NAME
NAME
□
□
STUDENT
ALUMNAE
DOB
STUDENT ID
SSN
MM/DD/YYYY
□
□
STAFF
FACULTY
-
-
/
/
STREET
CITY
STATE
ZIP
CELL PHONE
HOME PHONE
E-MAIL
SCHOOL
DEGREE
MAJOR
ADMISSION DATE / WORK STARTING DATE
GRADUATION DATE
TERMINATION DATE
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
/
/
/
/
/
/
ITEM
PURPOSE
FEE
NO.
□
Transcript
□
Enrollment Verification
□
Graduation Verification
□
Diploma/Certificate/Degree
□
Confirmation of Admission
□
Verification of Expected Graduation
□
Employment Verification
□
Verification of Tuition Payment
□
Tax Document
□
□
I-20
Other
*Fee: $10 per each item.
TOTAL
NOTE
:
*
(For Student’s Only)
Verification form is not valid without below officer’s confirmation & Applicant’s signature. Normal
processing time is
seven to ten working days
after receipt of the completed form. Student must not have
any existing holds or self-restrictions.
Applicant’s Signature
International Student’s Office
(F1 Student Only)
______________________________ ____/____/________ _______________________________ ____/____/________
Finance Officer’s Signature
Academic Officer’s Signature
________________________________ ____/____/______ _________________________________ ____/____/______
Received Date (Registrar’s Office)
Issued Date (Registrar’s Office)
________________________________ ____/____/______ _________________________________ ____/____/______
DISTRIBUTION:
□ Academic Affairs □ Registrar □ Finance Office (Optional) □ International Student Services (Optional)
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