Transcript Request Form - University of Connecticut
Office of the Registrar, Unit 4077T, Storrs, CT 06269-4077T
Forms are to be submitted by fax to 860-486-0062 or by mail to the address above.
Please print all information clearly and completely.
(Please note: your transcript cannot be released if there is a hold against your account.)
Student’s Name (Last, First, MI):__________________________________________________________
Date of Birth: _____/_____/_____ Student ID# (if known): _____________________________________
If you have ever attended the University of Connecticut under other names, please indicate them here:
_____________________________________________________________________________________
Student’s current home address: __________________________________________________________
Street: _______________________________________________________________________________
City: _______________________________________ State: __________ Zip: ____________________
Please indicate a phone number (with area code) or an e-mail address at which you may be reached. Phone: ___________________________ E-mail: ____________________________________________
Dates of attendance at UCONN:
First semester attended: ________________ Last semester attended: ______________________
Name and Address of a Single Recipient:Number of Copies to be sent:_________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Any additional recipients should be listed on page 2 of this form)
Please check this box if you are faxing more than one page. Number of pages: ________
I hereby authorize the University of Connecticut to release my transcripts to the recipients named on this form.
Date:_____/_____/_____ Signature:________________________________________________
University of Connecticut, Office of the Registrar, Transcript Request Form
Student's Name (Last, First, MI):_________________________________________________________________
Student ID # (if known): ______________________________________________________________________
Date: _______/_______/______ Signature: _______________________________________________________
Please Send Official Transcripts of my Academic Record to the following recipients
Please print all information clearly and completely.
Recipient #2
Number of transcripts: _________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Recipient #3
Number of transcripts: _________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Recipient #4
Number of transcripts: _________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Recipient #5
Number of transcripts: _________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
To indicate additional recipients, use additional forms. On the front of these additional forms be
sure to fill in your name, student ID, and date/signature.
University of Connecticut, Office of the Registrar, Transcript Request Form