Keiser University Transcript Request Form
PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION REQUESTED
Date: __________
PLEASE READ, COMPLETE FORM AND INCLUDE YOUR SIGNATURE BELOW.
In order to process a transcript request, all debt to the University must be paid in full and the student record must be complete. A $5.00 transcript processing fee is required. All payments must be made to the Bursar.
Student Name: __________________________________________________________
Student ID or SSN: ________________________ Student Date of Birth: ____________
Current Phone Number: _____________________ other number: _________________
Current Street Address: ___________________________________________________
City: __________________ State: _________________ Zip Code: _______________
Dates Attended: __________________________ |
_____________________________ |
(from) |
(to) |
I REQUEST MY OFFICIAL TRANSCRIPTS BE SENT TO
Name: ________________________________________________________________
Institution or Organization: _________________________________________________
Address: _______________________________________________________________
City: __________________ State: __________ Zip: _________ Country: ____________
I REQUEST TO PICK‐UP MY OFFICIAL TRANSCRIPTS
Please check one:
I will pick up my transcript
I authorize ________________________________________to receive my transcript.*
(full name of authorized person)
* will be required to present photo ID
I REQUEST DELIVERY BY CERTIFIED MAIL
Please check below, and pay additional fee to the Bursar
Certified mail $5.00
Student Signature: _______________________________________________________
Registrar Signature: __________________________ Date Processed: ______________
Revised 02/2020