Request A Transcript Form - Dyersburg State Community College printable pdf download

COMPLETE THIS FORM ONLY IF YOU ARE REQUESTING YOUR

DYERSBURG STATE COMMUNITY COLLEGE TRANSCRIPT

Please complete all information and FAX completed form to 731/286-3325 or mail to:

Dyersburg State Community College

Office of Records

1510 Lake Road

Dyersburg, TN 38024

DSCC transcripts will be issued free-of-charge for up to six copies per term. A fee of $1.00 will be assessed for

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each additional transcript.

DSCC Transcripts will not be issued until all debts or obligations to DSCC have been satisfied.

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Due to the costs involved, DSCC does not fax transcripts.

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Name and Date of Birth:

Last: _________________ First: __ ______________ Middle: __________ Former Name(s):_______________________

Birth Date: MM: _____ DD: _____ YY: _____

Contact Information:

Street Address: ______________________________________________________________________

City: ________________________________________ State: ________ Zip: __________

Email: _______________________________________ Phone: (___)___________________________

DSCC ID # ___________________________ OR Last 4 Digits of SSN: _______________

Are you currently enrolled at DSCC? ________ Number of transcripts requested: ________

Check all of the following that apply to your request:

_____ Mail my DSCC transcript to me at the address listed above.

_____ Mail my DSCC transcript to the address listed below.

_____ I will pick up my DSCC transcript at the DSCC One Stop Center on the Dyersburg Campus. [Allow 3-5 days for

processing.]

_____ Do not mail my DSCC transcript until the current term’s grades are posted.

_____ Do not mail my DSCC transcript until my degree is posted at end of term.

Mail my DSCC Transcript to Name/Address:

Individual’s Name or Specific Office (if applicable): _______________________________________

Business or Institution: _____________________________________________________________

Street Address: ___________________________________________________________________

City, State, Zip: ___________________________________________________________________

Individual’s Name or Specific Office: __________________________________________________

Business or Institution: _____________________________________________________________

Street Address: ___________________________________________________________________

City, State, Zip: ___________________________________________________________________

Signature (Required) __________________________________ Date _________________________

Request A Transcript Form - Dyersburg State Community College