Instructions: 1. This form will accompany requested material. PRINT LEGIBLY or TYPE. 2. Use a different form for each addressee. BE SURE TO CHECK ADDRESS FOR ACCURACY. 3. Failure to complete all items may delay processing of your request. 4. Allow at least 7 days for delivery. Requests are filled in the order received. 5. A receipt will be mailed to you once paperwork is processed. 6. Transcripts will not be issued for anyone financially obligated to the college.
PRINT Name: TU i.d.: Date: Telephone: Signature:____________________________ (authorization to release records) (please print out, sign above and send with payment) Fill-in Category: Current Student, Class of Graduate, Class of WD/LOA/Former Student Check-off items to be Sent: Official Transcript ($6.00 per transcript) Unofficial Transcript ($6.00 per transcript) School Certified Board Scores ($1.00 per set) (School certified national board scores are not used for state licensing; contact NBPME directly for official scores.) 3rd Year Clinical Evaluations (no charge) Class Rank (no charge) PRINT Recipient's Name and Address:
Indicate Action Desired: Send Hold for pick-up; paperwork is void if envelope seal is broken I authorize the following person to pick-up my academic records: PRINT name of designee: Fee(s) Attached:Cash $/ Check or Money Order (payable to TUSPM/ Voucher Check or Money Order number: Office Use Only: Date received_______ Date Processed_______ Amount Received $_______
PRINT Name and Address (Mailing Label):