Transcript Request - Ucla Center For Prehospital Care (Page 3 of 3) in pdf

Helpful Hint: Make sure you read our “Ordering Your Transcripts for UCLA Center

for Prehospital Care Programs and Answers to Frequently Asked Questions”

information sheet before you complete this form. Please note that Records beyond 7

years may not be accessible.

TRANSCRIPT REQUEST

USE INK. PLEASE PRINT CLEARLY.

PLEASE INDICATE THE TYPE OF TRANSCRIPT YOU ARE ORDERING.

If no indication is given, an academic transcript will be provided.



ACADEMIC ($10 each)

VERIFICATION ($10 each)

(your academic record, the course sections,

[your dates of attendance, your enrollment status, the

if applicable your grade point average (GPA), and date the course was

certificate you were awarded, including date; the date of your admission and expected date of

completed). For Paramedic Only. This not applicable for Paramedic Prep.

completion (if applicable)]

INFOR MAN TO IDENTIFY YOUR RECORD: Please complete all information requested.

SOCIAL SECURITY NUMBER or STUDENT ID NUMBER

BIRTHDATE (optional)

NAME (Last/ First/ Middle)

E-mail Address (optional)

NAME WHILE ATTENDING THE PROGRAM (if different from above)

TELEPHONE NO. (required)

(

)

STREET ADDRESS (include apartment number, etc.)

CITY

STATE

ZIP CODE

PROGRAM YOU ARE REQUESTING TRANSCRIPT(S) FOR ( box):

 EMT*  Paramedic Preparation*  Paramedic*  Phlebotomy

*SEE ATTACHED SHEET FOR INFORMATION ON REQUESTING COLLEGE CREDIT TRANSCRIPTS FOR APPLICABLE PROGRAMS. DO NOT USE THIS FORM.

DATES OF ATTENDANCE If requesting transcripts for multiple programs, list attendance dates separately.

START DATE OF ATTENDANCE (month/year)

LAST DATE OF ATTENDANCE (month/year)

Name of Program:

FEES



TOTAL NUMBER OF TRANSCRIPTS REQUESTED _________________ X $10 per transcript

PROCESSING:

 REGULAR PROCESSING (10-15 days) – no additional charge



 EXPEDITED PROCESSING (5 days) – additional $25 fee

 FAX to: (________)______________________ Attention: _____________________

MAILING INSTRUCTIONS:

 REGULAR US MAIL SERVICE – no additional charge



 VIA EXPRESS COURIER

(FED EX) X $30 (per envelope, if mailed separately)

* Note: Express delivery cannot be made to a PO Box Address. Recipient’s Telephone Number Required for Express Courier

Delivery: (_______) ___________________________



SPECIAL HANDLING (List any instructions, e.g., requesting paramedic course syllabus, requesting that

transcripts be sent to a different person/college, etc.)



HOLD TRANSCRIPTS FOR PICK UP ON

____________________ by _______________________

(date/time)

(name of designee for pick up)

Enclose a personal check or money order payable to UC Regents. Orders with incomplete information and/or insufficient payment will NOT be processed. All

TOTAL DUE:

outstanding obligations with UCLA CPC must be cleared before your transcript request can be processed.

YOUR SIGNATURE IS REQUIRED

I authorize release of my transcript as directed. I understand that my request will not be processed unless payment accompanies this form.

DATE OF REQUEST

 MAILING ADDRESS: Print name and complete address legibly.

For Office Use Only

Number of Copies Mailed to Address: _______

Payment Received: $_______ Date: ________

Transcript Request - Ucla Center For Prehospital Care Page 3

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