"Request Form for Transcript - Rockhurst University"

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Request for Transcript
Please note a transcript will NOT be released to a student whose financial obligations to the University have not been satisfied. Anyone with a hold will be contacted by email or mail to
notify them of the hold. If a hold is not cleared within 30 days the transcript request will be cancelled. It is the student’s responsibility to contact the Registrar’s office once the hold has
been removed. Please remember to sign the request form. A transcript request will not be processed without the student’s signature and until payment has been received.
STUDENT INFORMATION:
Required to identify your record. Please print clearly.
Student ID Number or Last 4 of SSN (Optional) _________________________________________________________________________
Last Name ____________________________________________________ First Name ____________________________________________ Middle_________________________
Previous/Maiden Name(s) ____________________________________________________________ Date of Birth _______________________________________________
Current Mailing Address _______________________________________________________________________________________________________________________________
City/Province ____________________________________________________ State/Country _____________________________ Zip/Postal Code _____________________
Phone ______________________________________________________________ E-mail _____________________________________________________________________________
Dates of Enrollment _______________________________________________ Degree Received _________________________________________________________________
Complete the following sections that are applicable
Complete the following sections that are applicable
RECIPIENT 1
RECIPIENT 2
If picking up or mailing to self, write “SELF” below.
1. Mailing Address – Print name and address of the recipient.
1. Mailing Address – Print name and address of the recipient.
2. Processing Options (Optional)
2. Processing Options (Optional)
No Charge
No Charge
 Attach a separate document (Ex: AMCAS, LSAC, etc.)
 Attach a separate document (Ex: AMCAS, LSAC, etc.)
 Hold for Degree
Fall / Spring / Summer
 Hold for Degree
Fall / Spring / Summer
 Hold for Degree
May / August / December
 Hold for Degree
May / August / December
FEE
FEE
3. Quantity _____________________
3. Quantity _____________________
x $7.50 each
x $7.50 each
4. Delivery Method and Additional Charges
4. Delivery Method and Additional Charges
 Standard USPS Mail
No Charge
 Standard USPS Mail
No Charge
 Fax
No Charge
 Fax
No Charge
 Express mail within the United States
$ 20.00
 Express mail within the United States
$ 20.00
 Same Day Pickup at Rock Stop
$ 25.00
 Same Day Pickup at Rock Stop
$ 25.00
 Hold for pickup at Rock Stop (must have a picture ID)
No Charge
 Hold for pickup at Rock Stop (must have a picture ID)
No Charge
5. I give permission for my Unofficial Transcript to be faxed by the
5. I give permission for my Unofficial Transcript to be faxed by the
Office of the Registrar at Rockhurst University. I do understand that
Office of the Registrar at Rockhurst University. I do understand that
this is not an official document. Initial: ________
this is not an official document. Initial: ________
Contact Person ________________________________________
Contact Person ________________________________________
Fax Number ___________________________________________
Fax Number ___________________________________________
TOTAL DUE FOR ORDER
$
PAYMENT INFORMATION (cash accepted by walk-in only)
SUBMIT REQUESTS TO:
Office of the Registrar
Rockhurst University
 Check or Money Order payable to Rockhurst University  Cash
1100 Rockhurst Road
Kansas City, MO 64110
 Visa  Master Card  Discover  Other ________________
or
Fax: 816-501-4677
Credit Card Number: _____________________________________________
Expiration Date: _____________________ Security Code: ______________
STUDENT SIGNATURE (REQUIRED): __________________________________________ Date: __________________
COULD NOT PROCESS (INITIAL) ____________ DATE CONTACTED ____________
OFFICE
PAYMENT RECEIVED $_______________________________
USE
BAD CC#
BAD FAX#
HOLD
NO SIGNATURE
NO PAYMENT
PAYMENT TYPE:
CHECK #_____________
CREDIT CARD
ONLY
DATE PROCESSED _____________________ FILLED BY (INITIAL) ______________
Print Form
Request for Transcript
Please note a transcript will NOT be released to a student whose financial obligations to the University have not been satisfied. Anyone with a hold will be contacted by email or mail to
notify them of the hold. If a hold is not cleared within 30 days the transcript request will be cancelled. It is the student’s responsibility to contact the Registrar’s office once the hold has
been removed. Please remember to sign the request form. A transcript request will not be processed without the student’s signature and until payment has been received.
STUDENT INFORMATION:
Required to identify your record. Please print clearly.
Student ID Number or Last 4 of SSN (Optional) _________________________________________________________________________
Last Name ____________________________________________________ First Name ____________________________________________ Middle_________________________
Previous/Maiden Name(s) ____________________________________________________________ Date of Birth _______________________________________________
Current Mailing Address _______________________________________________________________________________________________________________________________
City/Province ____________________________________________________ State/Country _____________________________ Zip/Postal Code _____________________
Phone ______________________________________________________________ E-mail _____________________________________________________________________________
Dates of Enrollment _______________________________________________ Degree Received _________________________________________________________________
Complete the following sections that are applicable
Complete the following sections that are applicable
RECIPIENT 1
RECIPIENT 2
If picking up or mailing to self, write “SELF” below.
1. Mailing Address – Print name and address of the recipient.
1. Mailing Address – Print name and address of the recipient.
2. Processing Options (Optional)
2. Processing Options (Optional)
No Charge
No Charge
 Attach a separate document (Ex: AMCAS, LSAC, etc.)
 Attach a separate document (Ex: AMCAS, LSAC, etc.)
 Hold for Degree
Fall / Spring / Summer
 Hold for Degree
Fall / Spring / Summer
 Hold for Degree
May / August / December
 Hold for Degree
May / August / December
FEE
FEE
3. Quantity _____________________
3. Quantity _____________________
x $7.50 each
x $7.50 each
4. Delivery Method and Additional Charges
4. Delivery Method and Additional Charges
 Standard USPS Mail
No Charge
 Standard USPS Mail
No Charge
 Fax
No Charge
 Fax
No Charge
 Express mail within the United States
$ 20.00
 Express mail within the United States
$ 20.00
 Same Day Pickup at Rock Stop
$ 25.00
 Same Day Pickup at Rock Stop
$ 25.00
 Hold for pickup at Rock Stop (must have a picture ID)
No Charge
 Hold for pickup at Rock Stop (must have a picture ID)
No Charge
5. I give permission for my Unofficial Transcript to be faxed by the
5. I give permission for my Unofficial Transcript to be faxed by the
Office of the Registrar at Rockhurst University. I do understand that
Office of the Registrar at Rockhurst University. I do understand that
this is not an official document. Initial: ________
this is not an official document. Initial: ________
Contact Person ________________________________________
Contact Person ________________________________________
Fax Number ___________________________________________
Fax Number ___________________________________________
TOTAL DUE FOR ORDER
$
PAYMENT INFORMATION (cash accepted by walk-in only)
SUBMIT REQUESTS TO:
Office of the Registrar
Rockhurst University
 Check or Money Order payable to Rockhurst University  Cash
1100 Rockhurst Road
Kansas City, MO 64110
 Visa  Master Card  Discover  Other ________________
or
Fax: 816-501-4677
Credit Card Number: _____________________________________________
Expiration Date: _____________________ Security Code: ______________
STUDENT SIGNATURE (REQUIRED): __________________________________________ Date: __________________
COULD NOT PROCESS (INITIAL) ____________ DATE CONTACTED ____________
OFFICE
PAYMENT RECEIVED $_______________________________
USE
BAD CC#
BAD FAX#
HOLD
NO SIGNATURE
NO PAYMENT
PAYMENT TYPE:
CHECK #_____________
CREDIT CARD
ONLY
DATE PROCESSED _____________________ FILLED BY (INITIAL) ______________
Transcript Request Form Request Form

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