Transcript Request Form - Molloy College printable pdf download

Molloy College

TRANSCRIPT REQUEST FORM

Revised 6/13

OFFICE OF THE REGISTRAR

1000 Hempstead Avenue

Transcript Fee: A $5.00 fee per copy is charged

P O Box 5002

for all transcripts (official, “student” copies,

Rockville Centre, NY 11571-5002

additional

copies) sent to any address or

picked-up. If your records are being held for

PLEASE PRINT YOUR CURRENT NAME AND ADDRESS:

any

reason,

your

request

WILL

NOT

processed until your records are cleared.

LAST NAME

FIRST

MIDDLE

In-person pick-up of your transcript requires

proof of identity. If you are having someone

ADDRESS

APT.#

else pick-up your transcript, you must give

them

written

authorization,

and

proof

CITY

STATE

ZIP CODE

identity must be shown.

Transcript requests may be mailed or faxed to

PREVIOUS NAMES/MAIDEN NAME:

516.323.4315. Email requests are not accepted.

PREVIOUS NAMES/MAIDEN NAME

Allow 3 – 5 business days to process transcript

requests. During peak times more processing

time may be required. Official transcripts are

mailed in a sealed envelope. Once opened, they

Indicate Dates of Attendance Undergraduate: _______________

are no longer “official”. Due to privacy policies,

Undergraduate Degrees Awarded: ___________________________

transcripts are never faxed.

Indicate Dates of Attendance/Graduate: ____________________

SSN: _________________________________

Graduate Degrees Awarded: ________________________________

Reason for Request: ______________________________________

_____________________________________

Student’s Signature (Required)

Hold for Final Grades for Semester: ______________________

Date: ________________________________

Hold for Degree Award notation: ________________________

Hold for Grade Change (Semester & Course): ______________

OFFICE USE ONLY:

PICK-UP REQUEST (Do not fill out additional mailing information.)

Amount paid: _______________________

Date received:

__________________

SEND ___ COPY TO THE NAME & ADDRESS LISTED BELOW:

Cash _____Check _ ___Money Order ____

Pick-up Promise Date: _______________

Processed on: _______________________

DISTRIBUTION:

White -

Window Envelope for Mailing

Yellow -

Registrar Copy

Pink -

Alumni Update Copy

Gold -

Student Receipt for In-person

THIS FORM WILL BE USED IN A WINDOW ENVELOPE. PLEASE PRINT

YOUR INFORMATION LEGIBLY IN THE MAILING WINDOW BOX.

---------------------------------------------------------------------------------------------------------------------------

CREDIT CARD AUTHORIZATION FORM FOR TRANSCRIPT REQUESTS

Cardholder’s Name: _________________________________________________

Card Number: ______________________________________________________

Expiration Date Required:

VISA

MasterCard

_________

I authorize $_______________ to be charged to the account above.

(Please indicate $5. for each transcript ordered.)

Required

Cardholder’s Signature

: ____________________________________

FOR OFFICE USE ONLY (BURSAR):

DATE:

INITIALS:

Transcript Request Form - Molloy College

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