Request Form For Official Student Transcript/records From Closed Proprietary Schools printable pdf download

REQUEST FORM FOR OFFICIAL STUDENT TRANSCRIPT/RECORDS

FROM CLOSED PROPRIETARY SCHOOLS

Contact our office at 225-342-4253 or 800-272-8090 to determine if we have your records.

Complete one form per school and mail to: (Choose from one of the mailing services below.)

Standard Mailing Address (US Postal Service):

Overnight Mailing Address (Fed-Ex, UPS, or US PostalService):

STATE OF LOUISIANA

BOARD OF REGENTS

PROPRIETARY SCHOOLS

1201 N. 3

STREET

P.O. BOX 3677

SUITE 6-200, CLAIBORNE BLDG.

BATON ROUGE, LA 70821

BATON ROUGE, LA 70802

(Please type or print in ink.)

Circle one:

Mr.

Miss.

Ms.

Mrs.

Your Name:____________________________________________________________________________________________________

Other/Maiden Name(s): ____________________________ _____________________________ __________________________

Date of Birth: ________________________________

Last 4 digits of your Social Security Number: _______________________

Home Address: _______________________________________________________________________________________________

_______________________________________________________________________________________________

What is the name of the school you attended? ______________________________________________________________________

In what city was this school located? _______________________What is the last year you attended?

: __________

(Approximate)

Have you ever requested a transcript from our office? Yes ___________

No ____________

(Fill out the following. Use the back of this page if you need more than 3 copies or more than one fax/email copy.)

What record(s) do you need?

Why do you need the record(s)?

Mail my record(s) in a sealed envelope to:

Examples: all records, transcripts

(Use only one example per line.)

Example: home address above, the address of the institution

and/or diploma/certificate,

Examples: personal, further my

or business. Records that are mailed from this office are

financial information, or other

education, employment, financial, or

official, faxed copies are unofficial.

(explain).

other (explain).

Official

Copy

($10.00)

Official

Copy

($5.00)

Official

Copy

($5.00)

Unofficial

Fax/Email

Attn: ____________________________________________

(included

with fee)

Fax #/Email: ______________________________________

FEE(S): There is a $10.00 processing fee for the first set of copies which includes: a cover letter, an official copy of requested record(s), first class return

postage of requested records, and if needed, fax/email copies of these documents. Additional copies are $5.00 each.

OVERNIGHT RETURN MAILING INSTRUCTIONS: Our fee does NOT include the cost of overnight return mail. If you want us to mail your records

overnight to a school or business, etc., include a prepaid-overnight, addressed envelope when you mail us this completed form and fee.

PAYMENTS: We do NOT accept cash, personal checks or credit/debit cards. Payment must be made with a “money order” or “business or

certified check” only, and made payable to “LA Board of Regents.”

I HAVE ENCLOSED $_____________ WITH THIS REQUEST. I UNDERSTAND THAT THE FEE IS REFUNDABLE IF NO DOCUMENTATION IS LOCATED.

I can be contacted at: Phone No.: __________________________________ E-Mail Address:___________________________________

SIGNATURE: _____________________________________________________ DATE: ________________________________________

(Our office will not process this request without a signature.)

Revised 1/2/2012

FOR OFFICE USE ONLY

Print pages: __________________________ Ck/MO # _________________________

Date: ______________ Amt:_________

Request Form For Official Student Transcript/records From Closed Proprietary Schools

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