PIMS Transcript Request Form

PIMS Transcript Request Form
Please note the following: All transcript requests must be accompanied by a $10.00 fee/ transcript in U.S. funds before processing. Payment is accepted in the form of Master Card, Visa, or Discover Card. PIMS is not responsible for incomplete or incorrect fax numbers and/or addresses. According to U.S. Dept. of Education, requests may not be made via email, due to privacy concerns.
Personal Information
Student Name:

First NameMiddle InitialLast Name
Former Name (If Applicable)
Name
Date of Birth:

MonthDayYear
Last 4 of Social Security #:
Email Address:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Current Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transcripts Should Be Sent To:
How do you want to get your transcripts?
NOTE:

You must fill out one of the below options based on your answer above in order to receive your transcript.
Name of Recipient:
Full Name of Transcript Recipient (Organization or Person)
Mail Transcript To:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax To:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Special Instructions:
Special delivery notes
Student Signature:
Date:

MonthDayYear
The student’s signature on the above line constitutes legal consent for release of the requested transcript AND also serves as legal authorization to charge a $10.00 fee per transcript to the credit card for which information is provided and entered directly below.

My Products

PIMS Transcript

Each official transcript is $10

$10.00 Quantity
Item subtotal:

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human
Should be Empty:

PIMS Transcript Request Form

Personal Information

Transcripts Should Be Sent To:

NOTE:

My Products