Mail to: College of Southern Maryland, Registrar’s Office (REG) Attn: Verification Requests, P.O. Box 910, La Plata, MD 20646-0910
or
you may Fax to: 301-934-7698
Please send each form only once by fax or
mail. Sending the same request multiple times increases workload and delays processing time.
VERIFICATION REQUEST FORM
Dat
e of Request ___________________
Fu
ll Name ____________________________________
First Middle Last
All former names_______________________________
Student ID# __________________
Last 4-digits of SSN _____________
Date of Birth (MM/DD/YYYY) __________________
Current Mailing Address:
Da
y Phone #__(_____)_________________Ext ______
Eve Phone # __(_____)_________________Ext ______
Cell Phone # __(_____)_________________Ext ______
E-mail address _________________________________
Stude
nt Signature_______________________________
(Legal signature required by PL93-380 Buckley Amendment, The Family
Education Rights and Privacy Act of 1974.)
*By signing, I also authorize CSM to update my name, address, e-mail,
and phone numbers in the data system.
Please indicate information to be verified:
_____Enrollment status (full-time or part-time)
Fall Spring Summer || Year______
_____Dates of attendance
_____Graduation date
__
___Degree(s)/Certification(s) Earned
_____G
rade point average
_____Other (specify)_________________________
Di
d you provide a form for us to complete?__ yes__ no
PLEASE SEND A LETTER TO THE FOLLOWING:
(please write legibly, provide # of copies needed, and provide
complete addresses)
Example:
The Positive Insurance Company
Attn: Jane Doe
100 Snail Mail Court
City, State, Zip
SEND ____ OFFICIAL LETTERS TO:
SE
ND ____ OFFICIAL LETTERS TO:
*I
f more than two locations needed, please provide a second request
form. All forms submitted must be completed in full.
*PLEASE NOTE*
FOR STUDENTS WHO ATTENDED 1958 1983 PLEASE COMPLETE THIS AREA
Most classes taken before Fall 1983 with Charles County Community College are on microfilm and we require at least a 6 week turnaround time to
process. To help us locate your records more easily, it is very important to provide the following information as accurately as possible.
Fi
rst Term of attendance __________________________
(e.g. Fall 1976)
La
st Term of attendance__________________________
(e.g. Spring 1978)
Ap
proximately how many credits did you complete? ______
Policy on E-mailing and Faxing Verifications:
The college does not e-mail any verifications due to security concerns.
We strongly prefer not to fax verifications due to concerns with security.
Only on rare occasion will we fax them for an emergency. If you request a
verification faxed, your signature on this page indicates that you are aware
that faxing the material is not completely secure, that third parties could
potentially gain access to your information during or after the send , and
that CSM is not responsible for any breach of information or identity theft.
Did you graduate with a certificate and/or a degree? If so, what were
they and what were the graduation dates?
_________________________________________________________
_________________________________
Did you attend Piney Point or Harry Lundburg School of Seamanship?
(if not sure, check “No”) Yes_____ No_____
Official verification of enrollment is available after the published drop date for the semester.
Prior to the drop date, CSM issues a pre-registration letter.
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