REGISTRAR STAFF ONLY
Date Received: _______________
Received By:_________________
Date Processed: ______________
� Mailed/USPS � Electronically Sent
Return to the Office of the University Registrar | IST Room 2052 | 863.874.8540 | registrar@floridapoly.edu
Official Transcript Request
Please complete all required fields in pen, and submit completed form and payment to Student Business Services
(Wellness Center, Room 1103). Transcript requests will not be processed if there are any holds on a student’s
account or fees owed to the university. Please allow up to five (5) business days for processing.
1. $10 USD Fee per transcript can be paid via your CAMS Account or in person with your request at the Bursar’s Office
2. Mailed requests accepted with check or money order, made payable to, Florida Polytechnic University
3. Requests can be e-mailed to Student Business Services at: sbs@floridapoly.edu or it can be mailed to:
Florida Polytechnic University, Student Business Services, 4700 Research Way, RM 1103, Lakeland, FL 33805
4. Transcripts will not be released if there is a balance on a student’s ledger; it must be paid in full
LAST: _________________________________________ FIRST: ___________________________________ MI: _____
STUDENT ID: __________________________________ EMAIL: _______________________________@floridapoly.edu
MAIDEN/OTHER NAMES USED: _____________________________________ DATE OF BIRTH: ____________________
ADDRESS: _____________________________________ CITY: _____________________ STATE: _____ ZIP: _______
PHONE: ______________________________ (Home or Cell) EMAIL:______________________@floridapoly.edu
Step 1: Transcript Process Instructions
Pickup Process/Send Now Hold for Current Semester Grades Hold for Degree Awarded
Other: _______________________________________________________________________________________
Step 2: Transcript Delivery Address (separate form required for each additional address)
School/Business Name: _____________________________ Attention/Department: _____________________________
Address: _____________________________________ City: ______________________ State: ______ Zip: _________
Step 3: Student Certification
I certify I am the above named student and authorize the release of my transcript to the address indicated above.
Student Signature: ____________________________________________________ Date: ______________________
Student Business Services
Date Transcript Fee Paid: ____________ Receipt Ref#: _________________ Fee Received By: ___________________
Complete as applicable: � Student Ledger Paid � Hold Removed Effective Date: __________________
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