*
Required
To request the release of your transcript, please fill out the form below. All transcripts will be mailed to your specified address or will be placed in your medical application. We do not fax transcripts. An electronic signature must be obtained before a transcript will be issued.
First
*
required
Last
*
required
Maiden Name
or name at time of attendance
Date of Birth
*
required
(mm/dd/yyyy)
Student ID
Current Address
*
required
Address 2
Apartment Number or Suite
City
*
required
State
*
required
Zip
*
required
Current Phone
*
required
Enter number without spaces or dashes
Dates of Attendance and/or Graduation
*
required
Class(es) Taken
How should the transcript be delivered?*
I request the transcript be mailed to me.
I request the transcript be placed in my medical application file.
Electronic Signature Agreement*
By selecting this box and typing your name below, you are signing this agreement electronically. You agree your electronic signature is the same as a handwritten signature for the purposes of validity, enforceability and admissibility.
Electronic Signature
*
required
Please send a confirmation email to the address below*: