Adult High School Transcript Release Form
Cleveland Community College
Learning Center
Date:______________________
Name: ________________________________________________ Soc. Sec. #: __________________________
D.O.B.: _____________________________
Address: ______________________________________________ Phone#: _______________________ Home
______________________________________________ ____________________Work/Cell
Graduation Date: _____________________
Last Date Attended: ___________________
Questions concerning requests should be directed to Jan Neal by phone at 704-669-4052 or email at
neal@clevelandcc.edu.
Please include with this form copies of your Driver’s License and Social Security Card.
Receiver Information:
Name Address/Fax #/Email # of Copies
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________ ________________________
Student’s Signature Date
_________________________________________________ ________________________
School Official’s Signature Date
Please read and complete the bottom portion of this form if:
Transcript should be mailed, faxed, or transferred electronically, or
Request is being done by mail, fax, or electronically.
For Office Use Only:
Date sent or picked up and
logged in _________________
click to sign
signature
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signature
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