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

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

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

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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@WRH WRHStudentEmailAddress

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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WRH,andthereleaseofanyadditionalacademicrecordsfromWRH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.

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

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

purposeofcreditevaluationtodeterminetheawardingofanAssociateDegr eefromWRH.Thisformalsoconfirms

myintentiontograduatefromWRHif/whenI’vemettheAA,AS,ASAorAAT–SecondaryMathematicsdegree

requirements.

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

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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