Student Separation Verification Form printable pdf download

Student Separation Verification Form

The student named below has requested to enroll in Adult Education classes at Southwestern Illinois

College. To comply with Illinois State regulations, we are respectfully requesting that you complete and

sign this form verifying that the student’s address is in your high school district and the student has

officially withdrawn or is not enrolled in classes at the high school named below.

Student Name: ________________________________________

Southwestern Illinois College

Adult Education Department

Address:______________________________________________

2500 Carlyle Av. Room 2273

City/State/Zip Code:____________________________________

Belleville, IL, 62221

Birth Date: __________________________

Office: 618-222-5525

Social Security Number:_________________________________

Fax: 641-5722

Student Signature___________________________________

Date:_________________________

High School Name:__________________________________ Telephone Number: ________________

High School Address__________________________________________________________________

FOR SCHOOL VERIFICATION, COMPLETE THE FOLLOWING

To be completed by the school representative

Representative Name ___________________________

(Printed)

Signature: ___________________________________

Title: _________________________________

Date signed:_______________________

Please affix your stamp or official seal here

Student Separation Verification Form