Current Student-Document Request Form
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1David Geffen School of Medicine at UCLA
Office Use Only
Student Affairs Office
Date Received
:
__________________
12-159 CHS, Box 951720
Amount Paid:
_______________
Los Angeles, CA 90095-1720
Date Completed
: __________________
Phone: 310-206-0434 / Fax: 310-794-9574
Current Student - Document Request Form
Not to be used for 4
year Away Elective Document Requests
th
Please allow
5-10 business days for processing, upon
receipt, depending on time of year and volume of requests. Please submit
document requests at least 2 weeks prior to any application or certification deadlines so we may better serve you.
The completed form(s) can be returned via email at registrar@mednet.ucla.edu, fax 310-794-9574 or by returning to the Registrar’s mailbox
in 12-159 CHS.
The SAO office hours are: M – F; 8:00am – 5:00pm.
Student Information - Please Print Clearly
Full Name: ______________________________________
Class of: _________
SID #: _____________________________
Contact Information (phone or MedNet Email): __________________________________________________________________
Signature: ________________________________________
Date: _________________________
Authorization signature required: I authorize release of information as directed on this Document Request Form
Request(s)
- Recipient address required in space provided below regardless of delivery method
Official Transcript
*
-
______
Returned in sealed envelope
with Dean’s signature/University embossed seal
# of Copies
Unofficial Transcript
-
# of Copies
______
Place in sealed envelope
not printed on transcript paper
Letter of Enrollment Verification
# of Copies
______
Place in sealed envelope
Letter of Good Standing
# of Copies
______
Place in sealed envelope
Jury Duty **-
Letter of exemption describing current registration and time requirements as a medical student. List full courthouse address
** Please note, you are responsible for sending the Letter of Exemption and Summons together to the courthouse
below.
Juror ID # ___________________________
Reporting Location #: _______
Group # : _______
Other (please specify): _______________________________________________________________________________
Special Instructions (please specify): ___________________________________________________
_______________
_
Loan Deferment Request – Cannot be completed by SAO.
Form must be completed by the School of Medicine FAO (12-109CHS)
Letter of Recommendation (scholarships, research, etc.)– Cannot be completed by Registrar.
–
Please complete Dean’s Letter of Recommendation form:
:
Sending Instructions
Please clearly print name and complete address to which document(s) should be addressed to. Complete a separate
Document Request Form when sending document(s) to multiple addressees.
I would like to PICK UP - you will receive an e-mail when
Regular Mail
Express Mail
($20.00 via UPS)
the document(s) is available to pick up.
Completion of this section REQUIRED
regardless of delivery method.
Complete recipient address to which you would like document(s) sent.
FAX TO
*
___________________________________
*SAO will not fax official transcripts
EMAIL TO: ___________________________________
*SAO will not email official transcripts
MAIL TO:
Last Updated: 2/1/2016
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