OFFICE OF THE REGISTRAR 101 N. College Avenue Annville, PA 17003-1400 (717) 867-6215 | Fax (717) 867-6018 www.lvc.edu/registrar

REQUEST FOR TRANSCRIPT PERSONAL INFORMATION

Student ID or SSN: ____________________ Name: ______________________________________________ Last First Middle

Date of Birth: ________________________ Maiden Name(s): ______________________________________

Home Address: ____________________________________________________________________________

_________________________________________________________________________________________

Phone Number: ___________________ Email Address: ____________________________________

I am a: □ Current Student □ Former Student–My Graduation Date/Last Date of Attendance: ____ /____ Month Year

PROCESSING INFORMATION Number of copies: ______________

Check one of the following options:

□     Please mail my transcript to:

                _________________________________________________________________________________

_________________________________________________________________________________

    City: ___________________ State: _______ Zip: _____________ Country: ___________________

□     Please fax an unofficial version of my transcript to: ______________________________________

Fax number: ________________

□   Please mail my transcript to me at the home address listed above*  

□       I wish to pick up my transcript. Please contact me when it is ready*  

□   Please email an unofficial version of my transcript in electronic (PDF) form to: ________________*  

*Please note: Some institutions/organizations may not consider transcripts produced in this manner to be official; they may require that a printed, sealed official transcript be mailed directly to them.

Special Handling: □ Hold for Degree □ Hold for Current Semester Grade □ Hold for Change of Grade  

SIGNATURE (REQUIRED TO PROCESS THIS REQUEST)  I authorize the release of my transcript as directed above:  

___________________________________________________________ __________________ Signature (Must be signed by the record holder) Date *Please remit a new request form for transcripts with differing processing information for each desired transcript.