PLEASE
PRINT CLEARLY
Requested B
y: Last : First: Date of Birth:
Requestor
’s Address: E-Mail:
City: Stat
e: Zip Code: Telephone Number:
Check One: Current Student Graduate Resigned – Date:
Name at tim
e of Graduation or Resignation: Class of:
Current Em
ployer:
Purpose of Request: Personal Employment College/University Scholarship
PAYMENT: (
Fee may change without notice).
Regular: $5.00 per copy (within 10 business days plus mailing time)
Rush: $10.00 per copy (within 1-2 business days plus mailing time)
Payable to the Los Angeles County College of Nursing and Allied Health.
Payment (check or money order) for transcripts must accompany written request.
Transcript requested in person: Make payment at any LAC+USC Medical Center Cashier Office, bring receipt
and transcript request form to the College.
Transcript requested by mail: Send payment and request form to the College at the above address.
Cost: Regular:
Rush:
# copies requested _____ X $5.00. Total:
# copies requested _____ X $10.00 Total:
Delivery: Pick Up Number of transcripts to be picked up:
Mail Number of transcripts to be mailed to this address:
(use separate sheet for each address)
Address:
City: State: Zip:
Signature:
Date:
Transc
ripts will be processed ONLY when the form is signed by the requestor and
requestor has been cleared of financial obligations if any.
For Office Use Only:
Transcript Receipt Number: Amount Paid:
Picked Up Date: Signature:
Mailed Date: Mailed By:
Revised: 11/2012; 01/2013; 07/2013; 09/2019
TRANSCRIPT REQUEST
click to sign
signature
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