Revised 10/09
URSINUS COLLEGE
P.O. BOX 1000
COLLEGEVILLE, PA 19426
TRANSCRIPT REQUEST
TRANSCRIPTS OR CERTIFICATIONS MAY BE WITHHELD IF OVERDUE OBLIGATIONS TO THE COLLEGE HAVE NOT BEEN SATISFIED
TRANSCRIPT FEE - $2.00 EACH PLEASE PRINT CLEARLY
Purpose of Request:___________________________________________________________________________________________
(Grad School; Scholarship; Employment; Transfer; etc.)
Please mail ____ transcript(s) to: ______________________________________________________________________________
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_____ transcript(s) to: ______________________________________________________________________________
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______transcript(s) to: ______________________________________________________________________________
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STUDENT’S SIGNATURE REQUIRED TODAY’S DATE
Due to the family rights and privacy act of 1974, a student’s signature is required for release of a transcript.
STUDENT’S SOCIAL SECURITY NUMBER ____________________________ BIRTHDATE_______________________
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LAST FIRST MIDDLE MAIDEN/PREVIOUS
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STREET TELEPHONE NUMBER
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CITY STATE ZIPCODE
DATE OF ENROLLMENT AT URSINUS COLLEGE:
FIRST ENROLLED (Month/Year) ____________________ LAST ENROLLED (Month/Year) __________________________
DIVISION: Day or Evening _________________________
GRADUATION DATE:_______________________ DEGREE OBTAINED ____________________________________
______ Hold until grades are available this term ______ Send Immediately
______ Hold until _______________________ degree is posted to record ______ Pick up (2 working days)
______ Hold for the following correction: _______________________________________________________________________
