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Transcript / Student Record Request

First Name*

Answer Required

Last Name*

Answer Required

Maiden Name (if applicable)

Answer Required

Birth Date*

Answer Required

Student ID#

Answer Required

Graduation year or last year attended Mica Peak*

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Phone Number*

Answer Required

Personal Email Address*

Answer Required

How would you like your transcript sent?

Answer Required

Email to Personal Email Address Above

Fax to Below Fax Number

Mail to Below Address

Fax Number

Answer Required

Please mail my transcript to

Contact Information

Name of Institution

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Additional Comments or requests

Answer Required

Confirmation Email*

Answer Required

Confirmation Email

Confirmation Email *

Email Required