Transcript/clinical Records Request Form
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1Transcript/Clinical Records Request Form
Incomplete forms may delay processing
Student Information
Name: _________________________________ Former/Maiden Name: ___________________________
Last 4 Digits of Social Security # __________ Date of Birth: ______________________________________
Current Address: ________________________________________________________________________
City: __________________________________ State: ____________ Zip: __________________________
E-Mail: __________________________________________ Phone: _______________________________
Request and Delivery Options
Number of Transcript Copies Requested: [ ] Official
[ ] Unofficial
[ ] Unofficial Transcript-FREE
[ ] Official Transcript- $10.00 per copy / FREE for Current Students
[ ] Expedited Official Transcript: $13.00 per copy (Mailed within 1-2 business days)
[ ] Copy of Clinical Records (immunization, etc.) - $10.00 per request / FREE for Current Students
Clinical Record requested: _________________________________________________________
1.
Please note that all transcript/Clinical record requests take 3-5 business days AND will not be available until payment is received.
2. All financial obligations must be met before transcripts will be released.
3. Transcripts
held for pick-up in the Registrar's/Academic Support Office will be held no longer than 30 days.
4. Unofficial transcripts
and copies of clinical records may be faxed or emailed. Official transcripts will not be faxed or issued by email.
5. Please make checks or money order payable to Denver School of Nursing and mail with this form or call 303-292-0015 ext. 3620 to pay by
credit card or provide the necessary information below.
[ ] Hold for pickup (Contact me by c Phone or c Email when ready)
[ ] Please mail transcript(s)/copy of clinical records to me using above address
[ ] Please email/fax copy of clinical records to the below:
[ ] Please mail transcript(s)/copy of clinical records directly to:
Recipient #1
Recipient #2
_______________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
→Student Signature: __________________________________________ Date: ______________←
(*Handwritten signature required for processing)
Mail this form to: Denver School of Nursing, Office of the Registrar, 1401 19th St., Denver, CO 80202
Fax this form to: 720-833-3916
Email this form to:
Official Use Only:
Date Request Rec'd: ______________ Date Payment Rec'd: __________________
Date Mailed: __________________________ Mailed by: ______________________________________________
Major Credit Card Number: ________________________________________Exp. Date: _______________
Cardholder Zip Code: ____________CVC Code: ________ Cardholder Phone: ________________________
Name of Cardholder: _____________________________________________________________________
All credit card information will be redacted once payment has been processed.
REV. 12/08; 01/11; 08/12
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