Molloy College
TRANSCRIPT REQUEST FORM
OFFICE OF THE REGISTRAR
1000 Hempstead Avenue
P O Box 5002
Rockville Centre, NY 11571-5002
PLEASE PRINT YOUR CURRENT NAME AND ADDRESS:
LAST NAME
FIRST
Transcript Fee: A $5.00 fee per copy is charged
for all transcripts (official, student copies,
additional copies) sent to any address or
picked-up. If your records are being held for
any reason, your request WILL NOT be
processed until your records are cleared.
MIDDLE
ADDRESS
APT.#
CITY
Revised 6/13
STATE
ZIP CODE
In-person pick-up of your transcript requires
proof of identity. If you are having someone
else pick-up your transcript, you must give
them written authorization, and proof of
identity must be shown.
Transcript requests may be mailed or faxed to
516.323.4315. Email requests are not accepted.
PREVIOUS NAMES/MAIDEN NAME:
PREVIOUS NAMES/MAIDEN NAME
Indicate Dates of Attendance Undergraduate: _______________
Undergraduate Degrees Awarded: ___________________________
Indicate Dates of Attendance/Graduate: ____________________
Graduate Degrees Awarded: ________________________________
Allow 3 5 business days to process transcript
requests. During peak times more processing
time may be required. Official transcripts are
mailed in a sealed envelope. Once opened, they
are no longer official. Due to privacy policies,
transcripts are never faxed.
SSN: _________________________________
Reason for Request: ______________________________________ _____________________________________
Hold for Final Grades for Semester: ______________________
Hold for Degree Award notation: ________________________
Hold for Grade Change (Semester & Course): ______________
PICK-UP REQUEST (Do not fill out additional mailing information.)
SEND ___ COPY TO THE NAME & ADDRESS LISTED BELOW:
PRINT
Students Signature (Required)
Date: ________________________________
OFFICE USE ONLY:
Amount paid: _______________________
Date received:
__________________
Cash _____Check _ ___Money Order ____
Pick-up Promise Date: _______________
Processed on: _______________________
DISTRIBUTION:
White - Window Envelope for Mailing
Yellow Registrar Copy
Pink Alumni Update Copy
Gold -
Student Receipt for In-person
THIS FORM WILL BE USED IN A WINDOW ENVELOPE. PLEASE PRINT
YOUR INFORMATION LEGIBLY IN THE MAILING WINDOW BOX.
--------------------------------------------------------------------------------------------------------------------------CREDIT CARD AUTHORIZATION FORM FOR TRANSCRIPT REQUESTS
Cardholders Name: _________________________________________________
Card Number: ______________________________________________________
VISA
MasterCard
Expiration Date Required: _________
I authorize $_______________ to be charged to the account above.
(Please indicate $5. for each transcript ordered.)
Cardholders Signature
Required: ____________________________________
FOR OFFICE USE ONLY (BURSAR):
DATE:
INITIALS:
