Transcript Requests (Page 2 of 2) in pdf

PUTNAM/NORTHERN WESTCHESTER BOCES

200 BOCES Drive, Yorktown Heights, NY 10598

The Tech Center at Yorktown – Health Services

Phone: (914) 248-2413

FAX: (914) 248-2410

TRANSCRIPT REQUEST FORM

First Name: _____________________________ Middle Name/Initial:___________________

Last Name: _____________________________ Maiden Name: _______________________

Street Address: ______________________________________________________________

City, State, Zip Code: _________________________________________________________

Home Phone: _________________________ Cell Phone: ____________________________

Dates of Attendance: From _________________________ To_________________________

Month

Day

Year

Month

Day

Year

 Pick Up Transcript

 Mail Transcript to Home Address

SELECT:

_________________________________________________________

If a transcript is to be mailed to a school, institution or organization, please print EXACT name,

address and office to which the transcript is to be mailed:

(duplicate form for additional requests)

(Name and Title)

(Name of School, Institution or Organization)

(Street Address, City, State, Zip Code)

Student Signature: ________________________________

Date: ____________________

FEE: $10.00 for each official transcript. Mail the completed form and payment to:

Putnam/Northern Westchester BOCES

Health Services Program – Tech Center – Room 202

200 BOCES Drive, Yorktown Heights, New York 10598-4399

Transcript Service Policy

When ordering by mail, attach a check or money order payable to P/NW BOCES. Any

outstanding tuition balance must be cleared before a transcript can be released. Transcripts

will be sent within 10 business days. Photo identification will be required to pick up a

transcript. Student’s signature is required to authorize request(s). Transcripts will not be

released to anyone without the student’s written consent.

For Office Use Only: Paid _______

Total # _______

Date Processed: __________

Transcript Requests Page 2