Revised February 3, 2017
Date Received: Bursar Fee Paid________________________
Initials _______________________________
Date _________________________________
Date Processed _______________________
Initials_______________________________
Notes:
If paying by credit card please include the following:
___VISA ___Master Card ___Discover
Name on Card:____________________________________________
Credit Card Number:________________________________________
Security Code Number:______________________________________
Expiration Date: ____________________________________
_______
*Billing Information (ONLY if different from above)
Street Address
City/State/Zip____________________________________
__________________________________
*DO NOT WRITE BELOW THIS LINE FOR OFFICE USE ONLY*
Checklist: Please be sure to include:
Sign the request
Requester is responsible for complete and accurate address
Please include $8.00 in the form of a check/MO or credit card information for a VISA,
MasterCard, & Discover for each transcript requested. Please make the check/MO
payable to SUNY Orange
Your Telephone Number with your request
If applying in person be sure to have picture ID
Please be aware transcripts are processed in the order in which they are received and will
take approximately 7-10 business days.
Office/Department:
City/State/Zip
Street Address
Transcript Addressed to:
Number of Copies to be sent to the below address: ________ ( Calculate fee of $8.00 per copy)
PRINT BELOW THE NAME AND/OR OFFICE AND ADDRESS WHERE YOU WANT THE TRANSCRIPT SENT
Hold for notation of degree. (Check one) ___ Dec. Graduate ___ Aug. Graduate ___ May Graduate
___ Community College in High School
Hold for current semester grades.
(Check one) ___ Fall ___ Spring ___ Summer 1 ___ Summer 2
NOW – Do not hold for grades or notation of degree
(Choose only one option per request)
WHEN DO YOU WANT YOUR TRANSCRIPT TO BE SENT:
If not currently enrolled please indicate approx. date of last attendance _______________
Are you currently enrolled at SUNY Orange ___Yes ___No
Telephone Number:Date:
Student ID#: A ___ ___ ___ ___ ___ ___ ___ ___
SSN ID#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Maiden (Former) Name:Date of Birth
Signature:
City/State/Zip
Student’s Current Address:
Student Name:
Transcript Request Form
Print and complete form then mail or fax with
appropriate fee to Records & Registration
SUNY Orange
Registrar’s Office
115 South Street
Middletown, NY 10940
Tel: (845) 341-4155
Fax: (845) 342-8662