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1. PRINTED Name
Last First
Middle
Current Address
Number and Street City/State/Zip Code
Last Four Digits of Social Security Number
Student ID Number (nine digits)
Birthdate
Daytime Telephone Number
2. What semester are you needing verification for?
Recipient’s Name
Number and Street
City/State/Zip Code
Name:
Fax Number:
Signature
Date
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
LOUISIANA DELTA COMMUNITY COLLEGE
Division of Student Affairs Department of Enrollment Services
Enrollment Verification Form
Please complete this form and FAX or MAIL to the following address:
Monroe Campus
Enrollment Services
7500 Millhaven Rd.
Monroe, LA 71203
Fax: 318-345-9002
Bastrop Campus
Student Success Services
729 Kammell St.
Bastrop, LA 71221
Fax: 318-556-7013
Ruston/Farmerville
Student Success Services
1010 James St.
Ruston, LA 71273
Fax: 318-251-4159
Tallulah /Lake Providence
Student Success Services
132 Old Hwy 65 South
Tallulah, LA 71284
Fax: 318-574-1868
West Monroe Campus
Student Success Services
609 Vocational Parkway
West Monroe, LA 71292
Fax: 318-396-6180
Winnsboro Campus
Student Success Services
1710 Warren St.
Winnsboro, LA 71295
Fax: 318-435-2166
3. Would you like your grade-point average (GPA) to appear on this verification form?
Yes No
4. How would you like for us to process your verification?
I will pick up this verification in person and understand I must present a picture ID to receive it.
(Once the enrollment verification period begins, please allow 2-3 business days for processing)
Please mail this verification to the following address:
Please fax this verification to:
5. Please affix your signature below (required).
Office Use Only:
Date Sent: By:
Delivery Method:
