AH-Enrollment Verification Request FA19.docx
ILLINOIS CENTRAL COLLEGE
ENROLLMENT SERVICES
ENROLLMENT VERIFICATION REQUEST FORM
Name Student ID# or Last 4 digits of SS#
Address City State Zip
Home/Cell Phone Work Phone
1. Check One 2. Check One
Loan Deferment (include deferment form) Will pick up
Good Student Discount (include insurance form) Mail to student at above address
Enrollment Verification Letter Mail in provided envelope
Other Other
3. List semester(s) to be verified:
Student Signature Date
Return form and documentation to: Enrollment Services
1 College Drive, Room L211
East Peoria, IL 61635-0001
Email: Enroll@icc.edu
click to sign
signature
click to edit
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