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 checks, 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
Social Security Number:*
Email Address:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Current Residential Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Copies:*
Transcripts Should Be Sent To:
How do you want to get your transcripts?*

I want my transcripts to be mailed.I want my transcripts to be faxed.I want to pick up my transcripts from Registrar's Office by hand.
NOTE:

You must fill out one of the below options based on your answer above in order to receive your transcript.
Full Name:

First NameLast Name
Mail To:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax To:
Please enter a valid phone number.
Phone Number:
Please enter a valid phone number.
Special Instructions:
Special delivery notes
Student Signature:*

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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.

Fee:

USDTranscript Fee

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

Should be Empty:

PIMS Transcript Request Form

Personal Information

Transcripts Should Be Sent To:

NOTE: