Transcript Request Form - Capital Region Boces

TRANSCRIPT REQUEST

(Note: Requests for transcripts related to the Adult Practical Nursing, Nurse Assistant or

other adult health careers programs must be accompanied by a payment of $5 in cash or

money order: no personal checks accepted.)

Name: __________________________________________________________________

Date of birth: _____________ Other names used: _______________________________

Current address: _________________________________________________________

Street

Apt.

_________________________________________________________

City

State

Zip

Telephone: ________________ E-Mail: _____________________________________

Year of Graduation: _______________

Program completed: _______________

PLEASE FORWARD AN OFFICIAL TRANSCRIPT TO:

Name of college/school/business: ___________________________________________

Attention: ______________________________________________________________

Address: _______________________________________________________________

_______________________________________________________________

Signature: ________________________________________ Date: ________________

Please return payment and Transcript Request form to:

Kathy Grey/Bursar

Health Careers

1015 Watervliet-Shaker Rd.

Albany, NY 12205

Receipt # ____________________

Office Use

Official Coy sent:

Unofficial copy sent to student (upon request only):

If you need the assistance of an interpreter, need material translated into any language other than English, please call Ottavio Lo Piccolo at (518) 862-4703 and leave a voice message. Thank you.

Si usted necesita asistencia de un interprete, o necesita traducion en espanol, y otros idiomas, por favor llame a Ottavio Lo Piccolo a este tel. (518) 862-4703, y deje un mensaje de voz. Gracias

The Capital Region BOCES does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs, activities, employment, and admissions; and provides equal

access to the Boy Scouts and other designated youth groups. The following person has been designated to handle inquiries regarding the non-discrimination policies: Robert Zordan, compliance

officer/coordinator, at , (518) 862-4910 or 900 Watervliet-Shaker Road, Albany, NY 12205. Inquiries concerning the application of the Capital Region BOCES

non-discrimination policies may also be referred to the U.S. Department of Education, Office for Civil Rights (OCR), 32 Old Slip, 26th Floor, New York, NY 10005, telephone (646) 428-3800

(voice) or (800) 877-8339 (TTY).