Registration & Records Office
Full-Time / Insurance Verification Request
Name: Date:
Student ID:
I authorize Rockland Community College to include my Social Security Number in
the verification.
O Yes O No Signature:
(If you check NO, you are acknowledging that your SS# will not be included in the verification
and your information may not be sufficient for the third party)
Semester: O Spring O Fall Year: 20___
I would like
number of copies
I would like my letter to be:
Picked up in one week: O
Mailed to the address below: O
Faxed to the number below O