Lackawanna College Trancsripts Form – Fill Out and Use This PDF

LACKAWANNA COLLEGE OFFICE OF THE REGISTRAR

Academic Record and Transcript Request

About your transcript request:

*There is a fee of $5.00 per transcript copy.

*Requests must be received by the Office of the Registrar at least 5 working days before the transcript is needed.

*This request may be faxed. The fee may be paid by credit card – please include your card type, number and expiration date with your request.

*ALL TRANSCRIPT REQUESTS MUST INCLUDE THE STUDENT’S SIGNATURE.

*Financial indebtedness to Lackawanna College may preclude the release of transcript.

Name: ___________________________________Last 4 digits of SS# or Student ID ________Date ________

Address: ____________________________________ City: ________________________________________

State: ______________ Zip Code: ____________________Phone: ( ) ____________________________

Send Transcripts to:

Name of Institute or Person: __________________________________________________________________

Address of Institute or Person: _________________________________________________________________

__________________________________________________________________

Request is for:

_____ An Official transcript. . (An official sealed transcript is to be presented unopened to

a third party. If seal is broken transcript is no longer considered official).

____ Student Copy.

If you want the Transcript sent out at the end of the semester please check here ______.

Are you a graduate of Lackawanna College? _____ Yes ____ No If Yes what Year? ___________________

Are you currently enrolled at Lackawanna College? ____ Yes ____ No If no what year did you attend? ______

Maiden name at college if applicable: __________________________________________________________

Signature: ____________________________________________ Date: ______________________________

Do not write in space below

Business Office Approval: _______________________________ Fee Paid: __________________________

Date Transcript Mailed: __________________________________Initials: __________________________

*If paying by credit card please complete the form on next page. Address/Fax Number see next page

When completed, please mail this form (both pages) to the following address:

LACKAWANNA COLLEGE OFFICE OF THE REGISTRAR 501 VINE STREET SCRANTON, PA 18509

Or Fax the form (including credit card type, number and expiration date) to:

(570) 504-7925

For Payment by Credit Card:

Credit Card Type (Visa/MasterCard/Discover)______________________________

Card #: ________________________________________3 security code on back of card _______________

Expiration Date: _________________________________

Name of Card Holder: ____________________________

I authorize Lackawanna College to charge the above account for my transcript fee(s).

________________________________________________

Authorized Signature

Date