HCClogo_new.gif (4254 bytes)

Request Form for Student Transcript
1) Fill in this form. 2) print it out. 3) Sign & Date 4) Mail it to Halifax Community College.
(NOTE: If this form is not signed and dated it cannot be processed!)

First Name:
Last Name:
Social Security number:
Phone:
I am requesting: An Official Copy of my transcript sent to a third party (Fee: $4.00)
A Student Copy of my transcript sent to me (Fee: $2.00)
Both (Fee $6.00)
This Transcript is for: Curriculum   Continuing Ed.(No charge for Continuing Ed. transcript)

Full Address where
Official Copy should be sent

Your Address
(if Student Copy is requested)

I authorize Halifax Community College to send my transcript to the above address(es)

Your Signature____________________________   Date  __________________

(NOTE: If this form is not signed and dated it cannot be processed!)

Halifax Community College
P.O. Drawer 809
Weldon NC 27890
Att: Registrar - Transcript Request

Please enclose $4.00 for official transcript, $2.00 for student transcript,
$6.00 for both; check or money order.