TRANSCRIPT REQUEST

If you would like to obtain a copy of your official transcript, please use this form. If you have any issues contact the The Healthcare Institute business office.

A transcript is a certified official copy of your permanent academic record. You are the only person authorized to request a copy of your transcript. Your written permission and signature are required to obtain your transcript and indicated by completing this form.
Please allow 10-15 business days for processing upon receipt of request and payment.
NOTE: Transcript requests WILL NOT be processed if there is a financial hold on your account.
Students may print UNOFFICIAL transcripts by accessing the student portal with your login information.

Date of Request

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Last 4 digits of your Social Security Number

Program Attended

Transcripts are only available for diploma level programs (i.e. Practical Nursing)

Program Start Date

YYYY

Program End Date

YYYY

Which version of your transcript are you requesting?

Unofficial ($10)

Official ($20)

Reason for Request

PLEASE PROVIDE MAILING INFORMATION FOR THE INTENDED RECIPIENT BELOW.

If you need multiple transcripts sent, you will need to submit a separate request for each.

Name of Institution to Send Transcript

ATTN:

First Name

Last Name

Address for Receiving Institution

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone # for Receiving Institution

(###)

###

####

Per the Family Educational Rights and Privacy Act (FERPA), I authorize The Healthcare Institute to release my academic transcript to the listed recipient provided on this form.

Student's Typed Name indicating Authorizing Signature

Today's Date

YYYY