Transcript Request

UW COLLEGES FAXED TRANSCRIPT REQUEST WITH CREDIT CARD PAYMENT

PLEASE FAX REQUEST TO (608) 265-9473

STUDENT’S NAME: __________________________________________________

STUDENT’S FAX NUMBER: ___________________________________________

FORMER NAME(s) WHILE ATTENDING: ________________________________

DATE OF BIRTH: ________________   SSN or ISO #: ______________________

CAMPUS/DATES OF ATTENDANCE: __________________________________

NUMBER OF TRANSCRIPTS REQUESTED: _________________

ADDRESS TO SEND TRANSCRIPT: (attach separate sheet for additional addresses)

 STUDENT SIGNATURE:_______________________  DATE: ________________

(Due to the Family Rights and Privacy Act of 1974, student signature is required for release of transcript)

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CARD HOLDER’S NAME: __________________________________________

                                                                                (as it appears on the card)

 CONTACT PHONE NUMBER (REQUIRED): ____________________________

 CARD TYPE:     [    ]  VISA          [    ]  MASTERCARD [     ]  DISCOVER

 ACCOUNT NUMBER: ______________________________________________

 EXPIRATION DATE: _______________________________________________

 PAYMENT FOR:   

[       ] TRANSCRIPTS  -- $3.00 each  (enter number of transcripts requested)   

[       ] UPS OVERNIGHT DELIVERY $18.00 ($15.00 per address + $3.00 per transcript fee)

Same day processing is only available with overnight delivery requests.  Requests must be received by 2:00 pm to receive same day processing. NOTE:  UPS WILL NOT DELIVER TO P.O. BOX ADDRESSES

 TOTAL AMOUNT CHARGED: _______________________

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(Office Use Only)

APPROVAL #: _______________      DATE:________________

 3/31/04