ReverseTransferTranscriptRequest/Release(RTTR/R)
REVERSETRANSFERTRANSCRIPTREQUEST/RELEASE
 EasternIllinoisUniversity
OfficeoftheRegistrar
600LincolnAvenue
Charleston,IL61920
2175813511
2175813412FAX
records@eiu.edu
Pleasecomplete,signandthenmail,fax,emailordeliverinpersontotheaboveaddress:
EIUStudentE# DACCStudentID# BirthDate(mm/dd/yy)
LastName First MiddleFormer/Maiden(ifApplicable)
CurrentStreetAddressEIUStudentEmailAddress
CityState Zip Telephone
LastCompletedTerm@EIU LastCompletedTerm@DACC DACCStudentEmailAddress
FERPAStatement:
UndertheFamilyEducationalRightsandPrivacyAct(FERPA)of1974,updatedJanuary2009,Iunderstand thatmy
educationalrecordscannotbereleasedwithoutmypermission.Iauthorize thereleaseofmyacademicrecordsfrom
EIUtoDACC,andthereleaseofanyadditionalacademicrecordsfromDACCtoEIU,in
ordertosharestudentdata
informationbetweenthetwoinstitutionswithouttheviolationofFERPA.IunderstandthatIhavetherighttorescind
thisreleaseagreementofmyacademicrecordsatanytimebynotifyingtheReg istraratEasternIllinois University.
IunderstandtheFERPAstatementandagreeto
mystudentrecordsbeingsharedbetweenEIUandDACCforthe
purposeofcreditevaluationtodeterminetheawardingofanAssociateDegreefromDACC.Thisformalsoconfirms
myintentiontograduatefromDACCif/whenI’vemettheASA(AssociateinScienceandArts)transferdegree
requirements.(Note:StudentswhohavecompletedtheirAES(AssociateinEngineeringScience)shouldnotcomplete
thisform.)
STUDENTSIGNATURE:________________________________________________________ DATE:___________________
ACOPYOFTHISFORMWILLBETRANSMITTEDWITHTHEOFFICIALTRANSCRIPTS
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome