Certification of Enrollment Request (Request for Transcript)

Please print the form below, fill in information, and sign it. Either mail it to Office of the Registrar, University of Pittsburgh at Titusville, Titusville, PA 16354 or Fax to 814-827-5405.

Student's Name:                                                                                                     

Social Security Number: ____________________________ ID Number:                                      

Telephone number:                                         E-mail address:                                              

Maiden or Previous Name:                                          

Current Address:                                                                                       

City:                                                        State:                       Zip:                                

Please provide a mailing address for the recipient of the transcript:

Name:                                                                                               

Address:                                                                                            

City:                                                         State:                            Zip:                                

Signature:                                                            Date Signed:                                    

YOUR REQUEST MUST BE SIGNED; OTHERWISE IT WILL BE RETURNED TO YOU.

There is a $3.00 charge for each transcript.  Attach check or provide the following information:

Circle one: Discover MasterCard Visa         Expiration date:___________________________  

Credit Card #:_________________________  Cardholder Telephone Number:_____________

Cardholder Name:_____________________________________________________

Cardholder Signature:_________________________________________________