ReverseTransferTranscriptRequest/Release(RTTR/R)
REVERSETRANSFERTRANSCRIPTREQUEST/RELEASE
 EasternIllinoisUniversity
OfficeoftheRegistrar
600LincolnAvenue
Charleston,IL61920
2175813511
2175813412FAX
records@eiu.edu
Pleasecomplete,signandthenmail,fax,emailordeliverinpersontotheaboveaddress:
EIUStudentE# SICStudentID# BirthDate(mm/dd/yy)
LastName First MiddleFormer/Maiden(ifApplicable)
CurrentStreetAddressEIUStudentEmailAddress
CityState Zip Telephone
LastCompletedTerm@EIU LastCompletedTerm@SIC SICStudentEmailAddress
FERPAStatement:
UndertheFamilyEducationalRightsandPrivacyAct(FERPA)of1974,updatedJanuary2009,Iunderstand thatmy
educationalrecordscannotbereleasedwithoutmypermission.Iauthorize thereleaseofmyacademicrecordsfrom
EIUtoSIC,andthereleaseofanyadditionalacademicrecordsfromSICtoEIU,in
ordertosharestudentdata
informationbetweenthetwoinstitutionswithouttheviolationofFERPA.IunderstandthatIhavetherighttorescind
thisreleaseagreementofmyacademicrecordsatanytimebynotifyingtheReg istraratEasternIllinois University.
IunderstandtheFERPAstatementandagreeto
mystudentrecordsbeingsharedbetweenEIUandSICforthepurpose
ofcreditevaluationtode terminetheawardingofanAssociateDegreefromSIC.Thisformalsoconfirmsmyintenti on
tograduatefromSICif/whenI’vemettheAAorASDegreerequirements.
STUDENTSIGNATURE:________________________________________________________ DATE:___________________
ACOPYOFTHISFORMWILLBETRANSMITTEDWITHTHEOFFICIALTRANSCRIPTS
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