THE UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER
OFFICE OF THE VICE CHANCELLOR FOR ACADEMIC, FACULTY, & STUDENT AFFAIRS
OFFICIAL TRANSCRIPT AUTHORIZATION REQUEST
TO:
Office of the Vice Chancellor for Academic, Faculty, & Student Affairs
FROM:
Faculty Member’s Current Name (First, Middle, Last)
CURRENT
DEPARTMENT:
CURRENT
COLLEGE:
I understand that official transcripts from my relevant degree(s) and/or coursework must be
received by The University of Tennessee Health Science Center as the campus moves forward with
independent SACS accreditation.
I authorize The University of Tennessee Health Science Center to secure official transcript(s) of my
relevant degree(s) and/or coursework from the institution listed below and to have those sent to:
The University of Tennessee Health Science Center
Office of Faculty Affairs, College of Medicine
910 Madison Avenue, Suite 1010
Memphis, TN 38163
Name of institution
attended:
Name when attending
institution:
Faculty Member’s Name when attending institution (First, Middle, Last)
Dates of attendance:
month
year
TO
month
year
Degree(s) obtained: (provide
details – see example)
Date of birth (MO/DA/YR):
Example for Degree(s) obtained: MS in Epidemiology, PhD in Anthropology, MD, PharmD
Faculty Member’s Signature
Date
Printed Name
Note:
 A separate Official Transcript Authorization Request (this document) must be signed for each
institution that you have attended or from which you graduated to authorize our office to obtain a
copy of your official transcript.
 If you did not graduate but only took courses, indicate the program/college responsible for the
courses.