Admissions and Records
701 S Mt. Vernon Ave. San Bernardino, CA 92410
Picture identification is required for ALL transactions at the San Bernardino Valley College Admissions and
Records Office. Anytime a student is unable to initiate a transaction, an appointed person may be authorized to
complete the transaction for the student by completing this form. With the exception of RUSH service for Transcripts
and Enrollment Verifications, a receipt of the completed transaction will be mailed directly to the student. (Revised:
In order to protect the privacy of student records (Ed Code 76243) and FERPA (Family Education Rights and
Privacy Act) of 1974, the following information is required for all proxy transactions:
Student’s Name
Last First M.I.
Mailing Address
Number Street City State Zip Code
Student’s SBVC ID# Date of Birth
Name of Appointed Person
Last First M.I.
Relationship to Student
Description of transaction to be completed: (For Example: Order transcripts, Submit high school paperwork, Pay
Fees, etc.)
Signature Date
Notary Public
State of County of
On this, the day of, 20 before me a notary public, the undersigned officer, personally appeared, known to me
(or satisfactorily proven) to be the person whose name is subscribed to the instrument within, and acknowledged that the
person executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
Notary Public signature
Official Use Only
A&R Staff Date Academic Year
No faxed, emailed or copies submitted by anyone other than student will be accepted
click to sign
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