Fillable Student Records Request Form printable pdf download

Student Records Request Form

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Commonwealth of Massachusetts

Division of Professional Licensure

Office of Private Occupational School Education

•

1000 Washington Street

Boston

Massachusetts

02118

STUDENT RECORDS REQUEST FORM

Use this form to request a copy of student records held by Division of Professional Licensure (DPL) or

student records formerly held by the Department of Elementary and Secondary Education. This form

should not be used if you are requesting student records from a closed school for which DPL is not the

repository (record holder). Please consult DPL’s list of closed schools to find the name of the correct

repository at

If DPL is the repository, please complete and sign this form and mail it to the address above along with a

stamped, self-addressed envelope. We cannot accept faxed or emailed copies of this request. At this

time there is no cost to request student records.

DPL will make every effort to complete this request within thirty (30) days. Please note that while DPL

may be the repository of some closed school’s student records, DPL only has those records provided by

the school at the time of its closure; therefore, DPL cannot guarantee that your student records are

available. You will be notified if your records cannot be located.

Student Name: _____________________________________________________________________________

(At time of attendance)

Last

First

School Attended:____________________________________________________________________________

Address of School Student Attended: ___________________________________________________________

Dates of Attendance:_________________________________________________________________________

Student’s Address: __________________________________________________________________________

Street

City

State

Zip

Phone: Day: __________________ Evening: ____________________ Email:___________________________

Last 4 digits of your Social Security Number: XXX-XX-________

Student Signature: _____________________________________ Date: ________________________________

TELEPHONE: (617) 727-5811

FAX: (617) 727-9932

TTY/TDD: (617) 727-2099

Student Records Request Form

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