Request Form For Official Student Transcript/records From Closed Proprietary Schools

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REQUEST FORM FOR OFFICIAL STUDENT TRANSCRIPT/RECORDS
FROM CLOSED PROPRIETARY SCHOOLS
Contact our office at 225-342-4253 or 800-272-8090 to determine if we have your records.
Complete one form per school and mail to: (Choose from one of the mailing services below.)
Standard Mailing Address (US Postal Service):
Overnight Mailing Address (Fed-Ex, UPS, or US PostalService):
STATE OF LOUISIANA
BOARD OF REGENTS
BOARD OF REGENTS
PROPRIETARY SCHOOLS
RD
PROPRIETARY SCHOOLS
1201 N. 3
STREET
P.O. BOX 3677
SUITE 6-200, CLAIBORNE BLDG.
BATON ROUGE, LA 70821
BATON ROUGE, LA 70802
(Please type or print in ink.)
Circle one:
Mr.
Miss.
Ms.
Mrs.
Your Name:____________________________________________________________________________________________________
Other/Maiden Name(s): ____________________________ _____________________________ __________________________
Date of Birth: ________________________________
Last 4 digits of your Social Security Number: _______________________
Home Address: _______________________________________________________________________________________________
_______________________________________________________________________________________________
What is the name of the school you attended? ______________________________________________________________________
In what city was this school located? _______________________What is the last year you attended?
: __________
(Approximate)
Have you ever requested a transcript from our office? Yes ___________
No ____________
(Fill out the following. Use the back of this page if you need more than 3 copies or more than one fax/email copy.)
What record(s) do you need?
Why do you need the record(s)?
Mail my record(s) in a sealed envelope to:
Examples: all records, transcripts
(Use only one example per line.)
Example: home address above, the address of the institution
and/or diploma/certificate,
Examples: personal, further my
or business. Records that are mailed from this office are
financial information, or other
education, employment, financial, or
official, faxed copies are unofficial.
(explain).
other (explain).
st
1
Official
Copy
($10.00)
nd
2
Official
Copy
($5.00)
rd
3
Official
Copy
($5.00)
Unofficial
Fax/Email
Attn: ____________________________________________
(included
with fee)
Fax #/Email: ______________________________________
FEE(S): There is a $10.00 processing fee for the first set of copies which includes: a cover letter, an official copy of requested record(s), first class return
postage of requested records, and if needed, fax/email copies of these documents. Additional copies are $5.00 each.
OVERNIGHT RETURN MAILING INSTRUCTIONS: Our fee does NOT include the cost of overnight return mail. If you want us to mail your records
overnight to a school or business, etc., include a prepaid-overnight, addressed envelope when you mail us this completed form and fee.
PAYMENTS: We do NOT accept cash, personal checks or credit/debit cards. Payment must be made with a “money order” or “business or
certified check” only, and made payable to “LA Board of Regents.”
I HAVE ENCLOSED $_____________ WITH THIS REQUEST. I UNDERSTAND THAT THE FEE IS REFUNDABLE IF NO DOCUMENTATION IS LOCATED.
I can be contacted at: Phone No.: __________________________________ E-Mail Address:___________________________________
SIGNATURE: _____________________________________________________ DATE: ________________________________________
(Our office will not process this request without a signature.)
Revised 1/2/2012
FOR OFFICE USE ONLY
Print pages: __________________________ Ck/MO # _________________________
Date: ______________ Amt:_________

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