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Transcript Request Form
Office of the Registrar-Transcripts
Indiana University Northwest
3400 Broadway
Gary, IN 46408-1197
FAX (219) 981-4200 and verify receipt by calling 219-980-6679
| Your Information: |
| Name |
________________________________________________ |
| Street |
________________________________________________ |
| City |
_____________________ |
State ___________ |
Zip ____________ |
| Phone |
( _____) _____-________ |
E-Mail ___________________________ |
Mail To:
| Name |
_______________________________________________________________ |
| Address Line 1 |
_______________________________________________________________ |
| Address Line 2 |
________________________________________________________________ |
| City |
_____________________ |
State ___________ |
Zip ___________ |
| ____ Number of Copies |
____ Hold until
the grades for the Current Semester are on the transcript |
| ____ Issue Immediately |
____ Hold until
my degree appears on the transcript |
| ____ Hold for a change of grade |
______________________
specify semester and expected grade |
I affirm that I am the above named student. In compliance
with Public Law 93-380, Family
Education
Rights and Privacy Act of 1974 (as amended), I hereby give my written
consent and
do therefore authorize
IUN to release my student records as noted. |
| Signature |
_________________________________________________________ |
| 10 Digit Student ID Number or SS# |
_____________________ Date
_______________________________ |
Special Handling:
| ____ If the recipient
of your transcripts has requested that we sign and seal the back of
the envelope check here |
| ____ Other: Please specify ___________________________________________________ |
Cost of Transcripts: $7.00
per copy (Faxed requests also require Transcript Fee Form.)
Payment must accompany transcript
requests (check, cash, money order, VISA, Mastercard or Discover) |
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