Student Keiser University Request – Fill Out and Use

Keiser University Transcript Request Form

PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION REQUESTED

Date: __________

PLEASE READ, COMPLETE FORM AND INCLUDE YOUR SIGNATURE BELOW.

In order to process a transcript request, all debt to the University must be paid in full and the student record must be complete. A $5.00 transcript processing fee is required. All payments must be made to the Bursar.

Student Name: __________________________________________________________

Student ID or SSN: ________________________ Student Date of Birth: ____________

Current Phone Number: _____________________ other number: _________________

Current Street Address: ___________________________________________________

City: __________________ State: _________________ Zip Code: _______________

Dates Attended: __________________________	_____________________________
(from)	(to)

I REQUEST MY OFFICIAL TRANSCRIPTS BE SENT TO

Name: ________________________________________________________________

Institution or Organization: _________________________________________________

Address: _______________________________________________________________

City: __________________ State: __________ Zip: _________ Country: ____________

I REQUEST TO PICK‐UP MY OFFICIAL TRANSCRIPTS

Please check one:

I will pick up my transcript

I authorize ________________________________________to receive my transcript.*

(full name of authorized person)

* will be required to present photo ID

I REQUEST DELIVERY BY CERTIFIED MAIL

Please check below, and pay additional fee to the Bursar

Certified mail $5.00

Student Signature: _______________________________________________________

Registrar Signature: __________________________ Date Processed: ______________

Revised 02/2020