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 MOTT 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 Mott Community
College for the purpose of credit evaluation to determine the awarding of an Associate Degree from Mott 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 Mott Community
College.
If it is appropriate to award an Associate Degree, my signature below gives permission to Mott Community College to award
the degree and notify me of the results without further intervention on my part.
Please note that if you were to return to MCC to pursue another degree, there may be financial aid implications due to the
number of credit hours attempted.
___________________________________________________________ ____________________________________
Signature Today’s Date
OFFICE USE ONLY – REVERSE TRANSFER AGREEMENT: Revised: December 11, 2012
CHECKED FOR HOLDS ____________ STAFF INITIALS ____________
REVERSE TRANSFER AGREEMENT
UNIVERSITY OF MICHIGAN-FLINT and MOTT COMMUNITY COLLEGE
OFFICE OF THE REGISTRAR
266 University Pavilion
Flint, MI 48502
(810) 762-3344 (810)762-3346 FAX
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 Mott
Community College.
I authorize the release of my academic records to Mott Community College and the release of academic records maintained by
Mott 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 Mott 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 such written revocation.
