*
Required
First Name
*
required
Middle Name
Maiden Name
*
required
Last Name
If different from maiden name
Year of Graduation
*
required
i.e. 1988
Email Address
*
required
Primary Phone
*
required
Phone Type
*
required
Please Select…
Home Phone
Work Phone
Cell Phone
Address
*
required
City
*
required
State
*
required
Zip Code
*
required
Birth Date
*
required
(mm/dd/yyyy)
Today's Date
*
required
(mm/dd/yyyy)
I am requesting:*
my medical records (only available for Class of 1989 or later)
my transcript
both my medical records and transcripts
Please send to:
Institution or Individual Name
*
required
Address
*
required
City
*
required
State
*
required
Zip Code
*
required
Would you like to send your medical records and transcript to a second institution or individual?*
Yes
No
Institution or Individual Name
*
required
Address
*
required
City
*
required
State
*
required
Zip Code
*
required
Would you like to send your medical records to a second institution or individual?*
Yes
No
Institution or Individual Name
*
required
Address
*
required
City
*
required
State
*
required
Zip Code
*
required
Would you like to send your transcript to a second institution or individual?*
Yes
No
Institution or Individual Name
*
required
Address
*
required
City
*
required
State
*
required
Zip Code
*
required
Total Cost
Please attach a copy of your photo ID.
Please scan/photograph both sides and attach as a PDF or JPEG. Title the file FIRST NAME_LAST NAME.
Max file size: 10 MB
If you need to attach a second file for the back of your photo ID, please load here.
Max file size: 10 MB
Signature
*
required
By typing your name into this box, authorization is granted to release transcript/medical record to the instituition(s) listed above.
Please send a confirmation email to the address below*: