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
