Transcript Request Form - Palau Community College
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1Registrar & Records Office
P.O. Box 9, Koror, Palau 96940
Phone: (680)488-2470 Fax: (680)488-2447
TRANSCRIPT REQUEST FORM
STUDENT INFORMATION – Required to identify your record (Please Print)
Social Security Number
Date of Birth
Full Name (Last, First, Middle)
PO Box or Street Address
City
State
ZIP Code
First Term Attended
Last Term Attended
Phone
Email Address
TRANSCRIPT REQUEST INFORMATION (Transcripts are sent now unless indicated below)
Regular
Rush
Send after _________________________ semester grades are posted
Request #1) Number of copies for the request below: ________
Request #3) Number of copies for the request below: ________
Hold for pick up by: ___________________________________________
Hold for pick up by: ___________________________________________
Address/Mail to: ______________________________________________
Address/Mail to: ______________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
OFFICE USE ONLY
Request #1 – Send by/date _____________________
OFFICE USE ONLY
Request #3 – Send by/date _____________________
Request #2) Number of copies for the request below: ________
Request #4) Number of copies for the request below: ________
Hold for pick up by: ___________________________________________
Hold for pick up by: ___________________________________________
Address/Mail to: ______________________________________________
Address/Mail to: ______________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
OFFICE USE ONLY
Request #2 – Send by/date _____________________
OFFICE USE ONLY
Request #4 – Send by/date _____________________
TRANSCRIPT FEES - Payment by check, money order (payable to Palau Community College), cash, or credit card is required in advance.
PROCESS
FEE
QTY
TOTAL FEE
Regular processing (2-5 business days)
$3.00
$
Rush processing (1 business day)
$5.00
$
CREDIT CARD PAYMENT INFORMATION
Cardholder’s Name
Credit Card Number
Exp Date (mm/yyyy)
Authorized Amount to Charge
Credit Card Type
Card Code (last 3 or 4 digits in signature block)
VISA
MasterCard
Cardholder’s Billing Address
Cardholder’s Daytime Phone
Signature _______________________________________________________________
Date of Request __________________________________
Authorization Signature Required: I authorize release of my transcript as directed on this Transcript Request Form.
Transcript Policies
For office use only
• Transcripts will not be released to students with obligations (account
Receipt Number: _____________ Amount paid: ____________________
balances, administrative holds) to the college.
Financial Clearance _________________ Initial: ____________________
• Transcripts are issued at the request of the student with their authorized
signature. Transcripts will not be released to a third party without the
Date transcript mailed _______________ Initial: ____________________
written consent of the student.
• Official transcripts of credits earned at other institutions are not
Date transcript picked up _____________ Initial: ____________________
available for distribution by Palau Community College.
Date transcript faxed ________________ Initial: ____________________
• A photo ID must be presented upon pick up of transcripts.
Revised 12/09/10
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