GALLIPOLIS CAREER COLLEGE
ACADEMIC TRANSCRIPT REQUEST RELEASE FORM
FEDERAL LAW PROHIBITS ACCESS TO STUDENT RECORDS TO ANY OTHER PARTY WITHOUT THE
WRITTEN CONSENT OF THE STUDENT.
Name _________________________________________________________________________________
Last
First
Middle
Last name while attending Gallipolis Career College
Social Security Number __________ - _____ - __________
Date of Birth _______________________
Address ________________________________________________________________________________
Street
City
State
Zip
Telephone (Main #): (______) - ______ - _____________ (Alternate #) (_____) - _____ - _____________
Last Year Attended _______________
Graduate:
[ ] YES
[ ] NO
$10.00 FOR EACH REQUEST
FIVE (5) BUSINESS DAYS FOR PROCESSING
I hereby authorize the release of my transcript information to the address and person below.
___________________________________
__________________________________
Signature
Date
NOTE: Most colleges will not accept a transcript brought in by a student; they prefer that it is sent
directly from one institution to another. If you are going to attend another college, it is in your
best interest to have your transcript sent directly to the proper college and/or admissions
representative.
Transcript to be sent to the Following Address
Complete School/Business Name:___________________________________________________________
Department ___________________________________ Attention: _________________________________
Street Address: __________________________________________________________________________
__________________________________________________________________________
City
State
Zip
******************************************************************************************************************************
OFFICE USE ONLY:
C:
Date Request Was Placed:
____________________
In Default
Yes
No
____________________
Outstanding Balance
Yes
No
$___________________
Request Taken By:
____________________
Transcript Sent:
____________________
Receipt Number
____________________
C. Shockey
J. Shirey
Credit Card [ ]
Check [ ]
Cash [ ]
Student File
* Attach Receipt
#_____________
Money Order [ ]
# ________________________