Form #714
Revised 06/2012
CURRICULUM TRANSCRIPT/TEST
SCORES RELEASE FORM
A SEPARATE FORM MUST BE USED FOR EACH RECIPIENT
REQUEST FULFILLED
BY __________
_____/_____/_____
P
LEASE MAIL REQUESTS BRUNSWICK COMMUNITY COLLEGE FAX (910) 754-9609
WITH
PAYMENT TO: OFFICE OF THE REGISTRAR OR REQUESTS TO: AND
PO BOX 30 CALL THE BUSINESS OFFICE TO PAY
SUPPLY, NC 28462-0030 AT (910) 755-7318
A. FULL NAME ________________________________________________________________________ B. DATATEL #__________________________________
Last First Middle or SOCIAL SECURITY NUMBER
C. NAME ATTENDED UNDER (if different from above) _______________________________________ D. DATE OF BIRTH ________/________/_____________
E. EMAIL ADDRESS _____________________________ @ __________________________ . ________ F. DAYTIME PHONE NUMBER (_____)______-_______
G. MAILING ADDRESS
_________________________________________________________________________________ ____________________________________ ______ _________
Address City State Zip
H. REASON FOR REQUEST (this information is requested for statistical purposes and is not released externally)
TRANSFERRING TO A 4-YEAR SCHOOL
SCHOLARSHIP APPLICATION
VERIFICATION OF PREVIOUS EDUCATION
TRANSFERRING TO ANOTHER 2-YEAR SCHOOL
EMPLOYMENT
MY OWN USE (Unofficial Copy)
OTHER (please specify) _____________________________________________________________________________________________________________________
BOX A – Demographic Information
***FOR INFORMATION REGARDING CONTINUING EDUCATION (CE) TRANSCRIPTS AND/OR ADULT HIGH SCHOOL DIPLOMA OR G.E.D. TRANSCRIPTS, CONTACT (910) 755-7380.***
A. DATE OF REQUEST ________/________/_____________
B. TYPE OF REQUEST
_____ COPIES OF MY CURRICULUM TRANSCRIPT
_____ COPIES OF MY PLACEMENT TEST SCORES
(P
LACEMENT TEST SCORES ARE ONLY VALID FOR 5 YEARS)
C. FULFILLMENT DATE
PROCESS IMMEDIATELY
(requests will be available one business day after receipt of this request)
HOLD FOR _____________ SEMESTER GRADES
HOLD FOR POSTING OF MY ______________________ DEGREE
SPECIFIC DEADLINE________/________/_____________
D. DELIVERY OF REQUEST
PICK-UP (available one business day after receipt of this request)
MAIL TO (specify address)
_____________________________________________________________ ______________________________________________
Individual, Institution, or Office Name To the Attention Of (optional)
_____________________________________________________________ ______________________________ _____ _______
Address City State Zip
BOX B – Request Details
By signing this document, the student gives BCC permission to release the transcripts and/or test scores to the named recipient.
_____________________________________________ ____________________________
Student’s Signature Date
If there are any fees/holds on the student’s account and/or this document does not contain the student’s signature below, this request will not be processed.
BOX C – Authorization
TRANSCRIPT CHARGES
effective July 1, 2012
$2 per transcript (available one business
day after receipt of the request and
payment).
$5 on-demand processing fee per
order for same-day service (on-demand
processing is not available during registration
days, grade due dates, the first day of
classes, etc.).
FOR EXAMPLE: 2 transcripts would cost $4 for normal,
next-day service, or $9 for same-day service ($4 for
transcripts + $5 on-demand processing fee).
CALL (910) 755-7318 TO MAKE YOUR PAYMENT
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome