Northwell Health Transcript Request Form

Affirmation: I (First Name Last Name)
Hereby request that an Official Transcript of my Northwell Health Emergency Medical Institute (EMI) program(s) be transmitted to the following educational institution:
Name of Institution:
Street Address

Street Address Line 2

CityState

Zip Code
Attention of:
If Other than a Learning Institution:
Affirmation: I (First Name Last Name)
Hereby request that an Official Transcript of my Northwell Health Emergency Medical Institute (EMI) program(s) be transmitted to the following recipient:
Name of Recipient:
Street Address

Street Address Line 2

CityState

Zip Code
Attention of:
REALEASE OF INFORMATION AUTHORIZATION
Affirmation: I (First Name Last Name)*
Hereby authorize the Course Sponsor Administrator of the Northwell Health Emergency Medical Institute (EMI) to release the above information to the organization(s) listened herein.
Signature*
Should be Empty:

Emergency Medical Insitute