2. Social Security Number: --             3. Date of Birth (mm/dd/yyyy): //

4. Legal Name: LastName, FirstName MiddleName

5. Other Name/s under which your records may be located (i.e. maiden name):
            Other Name: LastName, FirstName MiddleName

6. Legal Address (Permanent):

  Street: 
    City:  State:  Zip+4:   Country: 
E-Mail:  (If applicable.)

7. Date and Type of degree earned from MACC.   Date:   Degree Earned:

8. Transcript Type Requested.       Official Unofficial
Recipient Name
Address           
City, State ZIP

9. Transcript Type Requested.       Official Unofficial
Recipient Name
Address           
City, State ZIP

10. No. of Transcripts Requested (5 Maximum):

11. Please delay mailing transcript until grades for the current semester are posted.       Yes No

Your signature below authorizes MACC to release a copy of your record to the recipient shown on this form. It will take up to 5 working days for a transcript to be processed. No transcript will be furnished when Financial Aid, Student Services, Business Office or Library obligations have not been satisfied. Federal law prohibits release of this transcript or its contents to any party without the written consent of the student.

11. Signature_________________________________________ Date________________

12. Special Instructions: Fill in requested information, then print a copy of this page, sign and date, then either mail, email or fax this page to MACC as listed at top of form.