Fillable Uapb Enrollment Verification Request Form printable pdf download

Uapb Enrollment Verification Request Form

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UAPB Enrollment Verification Request Form

Verification requests submitted using this form are normally completed within 1 – 2 business days. Any verification not picked up

within THREE WEEKS will be destroyed and a new verification form must be submitted (the 1 – 2 day waiting period also applies).

**COMPLETE TO ENSURE PROPER IDENTIFICATION AND HANDLING**

Student ID or Social Security Number _____________________________ Date of Birth __________________________________

Full Name (Last, First, Middle) _________________________________________________________________________________

Former Name(s) Used ____________________________________ Phone Number (Area Code) ___________________________

Current Address ____________________________________________________________________________________________

Type of Verification:

 Enrollment

 Anticipated Graduation Date

 Academic Standing

 Other____________________________________________________________________________________________

Currently Enrolled:  Yes  No

If yes,  Undergraduate  Graduate If No, last semester attended:________________

I am requesting Enrollment Verification for:  Health Coverage Employment

 Government Agency  Other

(Students requesting verifications for health coverage should include the subscriber’s name )_____________________________

Student’s Signature __________________________________________

Date___________________________

I authorize the University of Arkansas at Pine Bluff to release the above information per this request.

Please submit this form to:

University of Arkansas to Pine Bluff

Academic Records

1200 N. University Dr. – Mail Slot 4983

Pine Bluff, Arkansas 71601

(870) 575-8487/Fax#: (870) 575-4608

Please select applicable options:

 Mailed

 Pick Up

 Fax ($6.00 fee, check or money order )

If mailing, submit EXACT ADDRESS where enrollment verification should be sent and if faxing, submit FAX NUMBER AND

CONTACT PERSON to which enrollment verification should be sent:

Name_________________________________________________

Name________________________________

Address________________________________________________

Fax#_________________________________

City, State, Zip__________________________________________

Please print legibly and submit copy of photo

id for request not submitted in person.

Uapb Enrollment Verification Request Form

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