Document Request Form - Alumni

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Office of the Registrar
One Gustave L. Levy Place
Annenberg Building-Room 1330
Box 1257
New York, NY 10029-6574
Phone 212.241.6691
Facsimile 212.369.6013
E-mail: :
Registrar@mssm.edu
DOCUMENT REQUEST FORM - ALUMNI
Name
Class
Date
SS# or Life
 Phone #
E-Mail Address
Number
CONTACT INFORMATION
(this information must be filled in or risk delay in processing)
Mailing Address
 
Phone
Home Phone
Cell Phone
Please allow seven to ten (7-10) business days for processing. Documents will not be issued for graduates who
have not met their financial obligations to Mount Sinai School of Medicine.
Mail Document To:
Same as Mailing Address
I will pick up document (official transcripts will be in sealed envelopes)
Each new or duplicate diploma requested is $50 each. Request must be accompanied by
Diploma
notarized photo of person holding diploma and a check or notarized photo of person.
Please note: We do NOT keep copies of you diploma.
Transcript
Student Copy - $10 per copy
Official Transcript
Student Copy - $10 per copy
MSPE/Dean’s Letter
$10 per copy – will ONLY send to Programs
Completion of State Board
$10 per copy
Licensures
Certification of MD Degree
No Fee
Letter of Good Standing (confirms status, year of studies, expected graduation) – No Fee
Enrollment Verification
Attached forms to be completed by Registrar and/or Associate Dean
I authorize the Mount Sinai School of Medicine to release the documents as indicated above.
Alumni Signature
Date
Office Use Only
Official Transcript sent on ______ / ______ / ______ by ______________________________________________
Revised February 2011

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