AUTHORIZATION FOR FINAL TRANSCRIPT

Authorization for Final Transcript or Release of Records
Alumni/Student Information:
First and Last Name at the time of graduation*

Student's First NameStudent's Last Name
Graduation Year *
Alumni/Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alumni/Student Birthdate*

MonthDayYear
Date
Alumni/Student Personal Email*
example@example.com
College, School, or Agency Name Information
Institution Name
Name of College, School, or Agency
Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Institution Email (for electronic submissions)
example@example.com

Payment

Transcript request fee

$5.00

Total

$0.00

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

Allow five (5) business days from the date of receipt to process your request. It is the student’s responsibility to complete and sign this form. Incomplete authorization forms will not be processed. If you have any questions or concerns, please email registrar@delasallenola.com.
Signature

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Should be Empty:

Authorization for Final Transcript or Release of Records