Request Your Transcript Western Suffolk Boces
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1Placement Office
(631) 667-6000 Ext 114
Wilson Technological Center
(631) 623-4902 (fax)
17 Westminster Avenue
Dix Hills, NY 11746
REQUEST FOR OFFICIAL TRANSCRIPT
Complete the entire form and return to the Placement Office at the above address.
NOTE: There is a $5.00 fee to obtain an official copy of your transcript.
Mail Requests:
Use money order or MasterCard or Visa or Discover Card
Fax or Email Requests: Use MasterCard or Visa or Discover Card
In-person Requests:
Use cash or money order or MasterCard or Visa or Discover Card
Where should we send your official transcript of the coursework you took while attending
Western Suffolk BOCES? (Please print address as it should appear on the envelope).
Name: ______________________________________________________________________
Print either the name of the school or your own name. We will send the transcript to the name given here.
Address: ____________________________________________________________________
Print the address of the school or your own address. We will send the transcript to the address given here.
Town: ________________________________________ State: ______ Zip: ____________
Print the town/state of the school or your own town. We will send the transcript to the town/state given here.
I attended BOCES/Wilson Tech from ______________ to______________ as (please check):
High School Student
Yes
No
Adult Student as a
Day Student
Night Student
Course Name: ________________________ Course Location___________________________
Birthdate: __________/__________/__________
Day
Month
Year
While in attendance, my name was:
_______________________ _______________________ _______________________
First
Middle
Last
If you have any questions about my request, contact me at
Home Phone (_____) _______-___________ Cell Phone (_____) _______-___________
Date_______________ Signature___________________________________
Method of Payment:
Cash
Money order
Visa
MasterCard
Discover Card
Credit Card # _______________________________
Security Code (found on back of card) _______ Expiration Date_______/_______
Card Holder Name __________________________________________________________
Card Holder Address ________________________________________________________
Town __________________________________State_____ Zip___________
_____________________
Card Holder Signature ___________
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