Fill - Free fillable Form 2175813511: REVERSETRANSFERTRANSCRIPTREQUEST/RELEASE EasternIllinoisUniversity OfficeoftheRegistrar 600LincolnAvenue Charleston,IL61920 (Eastern Illinois University) PDF form

ReverseTransferTranscriptRequest/Release(RTTR/R)

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 REVERSETRANSFERTRANSCRIPTREQUEST/RELEASE

  EasternIllinoisUniversity

OfficeoftheRegistrar

600LincolnAvenue

Charleston,IL61920

217‐581‐3511

217‐581‐3412FAX

records@eiu.edu



Pleasecomplete,signandthenmail,fax,emailordeliverinpersontotheaboveaddress:



EIUStudentE#    LLCStudentID#  BirthDate(mm/dd/yy)



LastName  First  MiddleFormer/Maiden(ifApplicable)

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CurrentStreetAddressEIUStudentEmailAddress

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CityState  Zip Telephone

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LastCompletedTerm@EIU LastCompletedTerm@LLC LLCStudentEmailAddress



FERPAStatement:

UndertheFamilyEducationalRightsandPrivacyAct(FERPA)of1974,updatedJanuary2009,Iunderstand thatmy

educationalrecordscannotbereleasedwithoutmypermission.Iauthorize thereleaseofmyacademicrecordsfrom

EIUtoLLC,andthereleaseofanyadditionalacademicrecordsfromLLCtoEIU,in

ordertosharestudentdata

informationbetweenthetwoinstitutionswithouttheviolationofFERPA.IunderstandthatIhavetherighttorescind

thisreleaseagreementofmyacademicrecordsatanytimebynotifyingtheReg istraratEasternIllinois University.



IunderstandtheFERPAstatementandagreeto

mystudentrecordsbeingsharedbetweenEIUandLLCforthe

purposeofcreditevaluationtodeterminetheawardingofanAssociateDegreefromLLC.Thisformalsoconfirmsmy

intentiontograduatefromLLCif/whenI’vemettheAssociateDegreerequiremen ts.

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STUDENTSIGNATURE:________________________________________________________ DATE:___________________

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ACOPYOFTHISFORMWILLBETRANSMITTEDWITHTHEOFFICIALTRANSCRIPTS

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Form 2175813511: REVERSETRANSFERTRANSCRIPTREQUESTRELEASE EasternIllinoisUniversity OfficeoftheRegistrar 600LincolnAvenue Charleston,IL61920 (Eastern Illinois University)

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