Please complete, sign and then mail, fax, email or deliver in person to the above address.
_________________________________________________________________________________________________
UM-Flint Student ID Number Community College Student Number Birth date
(mm/dd/yy)
_________________________________________________________________________________________________
Last Name First Middle Former (If Applicable)
_________________________________________________________________________________________________
Current Street Address Uniqname
_________________
________________________________________________________________________________
City State Zip Telephone
Requests completed using this form will be sent automatically to Kalamazoo Valley Community College
My signature below is agreement that:
I understand the FERPA statement and agree to my student records being shared between UM-Flint and Kalamazoo Valley
Community College for the purpose of credit evaluation to determine the awarding of an Associate Degree from Kalamazoo
Valley Community College.
If applicable, an appropriate Associate Degree will be awarded based on my records, requirements of the degree, and credits
toward degree. The awarded Associate Degree may not be the degree I was pursuing while a student at Kalamazoo Valley
Community College.
If it is appropriate to award an Associate Degree, my signature below gives permission to Kalamazoo Valley Community
College to award the degree and notify me of the results without further intervention on my part.
________
___________________________________________________ ____________________________________
Student Signature Today’s Date
OFFICE USE ONLY – REVERSE TRANSFER AGREEMENT: Revised: May 22, 2014
DATE SUBMITTED ______________ TIME SUBMITTED ______________ CHECKED FOR HOLDS ____________
STAFF INITIALS ____________
REVERSE TRANSFER AGREEMENT
UNIVERSITY OF MICHIGAN-FLINT and
KALAMAZOO VALLEY COMMUNITY COLLEGE
OFFICE OF THE REGISTRAR
266 University Pavilion
Flint, MI 48502
(810) 762-3344
The Family Rights and Privacy Act (FERPA) of 1974, protects the privacy of student educational records, including transcripts, by
placing certain restrictions on the disclosure of that information. As a result, your written authorization is required in order for the
University of Michigan-Flint to release your educational records to facilitate the reverse transfer credit agreement with Kalamazoo
Valley Community College.
I authorize the release of my academic records to Kalamazoo Valley Community College and the release of academic records
maintained by Kalamazoo Valley Community College to UM-Flint without prior notice and for the purpose of credit evaluation to
determine the awarding of an associate’s degree or other credential of value from Kalamazoo Valley Community College. This
authorization will remain in effect for one-year from the date of the authorization below unless revoked in writing. I understand
that I have the right to rescind this at any time by notifying the Office of the Registrar at the University of Michigan-Flint in
writing of my decision. I understand that such revocation will not affect any disclosures previously made before receipt of any
