"Transcript Request Form - Molloy College"

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Molloy College
TRANSCRIPT REQUEST FORM
Revised 6/13
OFFICE OF THE REGISTRAR
1000 Hempstead Avenue
Transcript Fee: A $5.00 fee per copy is charged
P O Box 5002
for all transcripts (official, “student” copies,
Rockville Centre, NY 11571-5002
additional
copies) sent to any address or
picked-up. If your records are being held for
PLEASE PRINT YOUR CURRENT NAME AND ADDRESS:
any
reason,
your
request
WILL
NOT
be
processed until your records are cleared.
LAST NAME
FIRST
MIDDLE
In-person pick-up of your transcript requires
proof of identity. If you are having someone
ADDRESS
APT.#
else pick-up your transcript, you must give
them
written
authorization,
and
proof
of
CITY
STATE
ZIP CODE
identity must be shown.
Transcript requests may be mailed or faxed to
PREVIOUS NAMES/MAIDEN NAME:
516.323.4315. Email requests are not accepted.
PREVIOUS NAMES/MAIDEN NAME
Allow 3 – 5 business days to process transcript
requests. During peak times more processing
time may be required. Official transcripts are
mailed in a sealed envelope. Once opened, they
Indicate Dates of Attendance Undergraduate: _______________
are no longer “official”. Due to privacy policies,
Undergraduate Degrees Awarded: ___________________________
transcripts are never faxed.
Indicate Dates of Attendance/Graduate: ____________________
SSN: _________________________________
Graduate Degrees Awarded: ________________________________
Reason for Request: ______________________________________
_____________________________________
Student’s Signature (Required)
Hold for Final Grades for Semester: ______________________
Date: ________________________________
Hold for Degree Award notation: ________________________
Hold for Grade Change (Semester & Course): ______________
OFFICE USE ONLY:
PICK-UP REQUEST (Do not fill out additional mailing information.)
Amount paid: _______________________
Date received:
__________________
SEND ___ COPY TO THE NAME & ADDRESS LISTED BELOW:
Cash _____Check _ ___Money Order ____
Pick-up Promise Date: _______________
PRINT
Processed on: _______________________
DISTRIBUTION:
White -
Window Envelope for Mailing
Yellow -
Registrar Copy
Pink -
Alumni Update Copy
Gold -
Student Receipt for In-person
THIS FORM WILL BE USED IN A WINDOW ENVELOPE. PLEASE PRINT
YOUR INFORMATION LEGIBLY IN THE MAILING WINDOW BOX.
---------------------------------------------------------------------------------------------------------------------------
CREDIT CARD AUTHORIZATION FORM FOR TRANSCRIPT REQUESTS
Cardholder’s Name: _________________________________________________
Card Number: ______________________________________________________
Expiration Date Required:
VISA
MasterCard
_________
I authorize $_______________ to be charged to the account above.
(Please indicate $5. for each transcript ordered.)
Required
Cardholder’s Signature
: ____________________________________
FOR OFFICE USE ONLY (BURSAR):
DATE:
INITIALS:
Molloy College
TRANSCRIPT REQUEST FORM
Revised 6/13
OFFICE OF THE REGISTRAR
1000 Hempstead Avenue
Transcript Fee: A $5.00 fee per copy is charged
P O Box 5002
for all transcripts (official, “student” copies,
Rockville Centre, NY 11571-5002
additional
copies) sent to any address or
picked-up. If your records are being held for
PLEASE PRINT YOUR CURRENT NAME AND ADDRESS:
any
reason,
your
request
WILL
NOT
be
processed until your records are cleared.
LAST NAME
FIRST
MIDDLE
In-person pick-up of your transcript requires
proof of identity. If you are having someone
ADDRESS
APT.#
else pick-up your transcript, you must give
them
written
authorization,
and
proof
of
CITY
STATE
ZIP CODE
identity must be shown.
Transcript requests may be mailed or faxed to
PREVIOUS NAMES/MAIDEN NAME:
516.323.4315. Email requests are not accepted.
PREVIOUS NAMES/MAIDEN NAME
Allow 3 – 5 business days to process transcript
requests. During peak times more processing
time may be required. Official transcripts are
mailed in a sealed envelope. Once opened, they
Indicate Dates of Attendance Undergraduate: _______________
are no longer “official”. Due to privacy policies,
Undergraduate Degrees Awarded: ___________________________
transcripts are never faxed.
Indicate Dates of Attendance/Graduate: ____________________
SSN: _________________________________
Graduate Degrees Awarded: ________________________________
Reason for Request: ______________________________________
_____________________________________
Student’s Signature (Required)
Hold for Final Grades for Semester: ______________________
Date: ________________________________
Hold for Degree Award notation: ________________________
Hold for Grade Change (Semester & Course): ______________
OFFICE USE ONLY:
PICK-UP REQUEST (Do not fill out additional mailing information.)
Amount paid: _______________________
Date received:
__________________
SEND ___ COPY TO THE NAME & ADDRESS LISTED BELOW:
Cash _____Check _ ___Money Order ____
Pick-up Promise Date: _______________
PRINT
Processed on: _______________________
DISTRIBUTION:
White -
Window Envelope for Mailing
Yellow -
Registrar Copy
Pink -
Alumni Update Copy
Gold -
Student Receipt for In-person
THIS FORM WILL BE USED IN A WINDOW ENVELOPE. PLEASE PRINT
YOUR INFORMATION LEGIBLY IN THE MAILING WINDOW BOX.
---------------------------------------------------------------------------------------------------------------------------
CREDIT CARD AUTHORIZATION FORM FOR TRANSCRIPT REQUESTS
Cardholder’s Name: _________________________________________________
Card Number: ______________________________________________________
Expiration Date Required:
VISA
MasterCard
_________
I authorize $_______________ to be charged to the account above.
(Please indicate $5. for each transcript ordered.)
Required
Cardholder’s Signature
: ____________________________________
FOR OFFICE USE ONLY (BURSAR):
DATE:
INITIALS: