First name Initial Last name

Previous last name Social Security #

Address City

State Zip Phone (include area code)

Did you attend Ivy Tech prior to 1990? yes   no     Number of copies :

Submit a separate release for each request. If multiple copies go to the same address only one form is necessary.

Send transcript to Attn:

Address City

State Zip

Choose one: Send transcript now, NOT including this term's grades.

Send after this term's grades are processed.  Send after graduation statement is complete.

Note: If your record shows that your account is encumbered because of financial indebtedness to the College, no official record will be released until the encumbrance has been cleared.

Payment
The first official transcript is free. There is a $5 fee per transcript for each subsequent official transcript released. Unofficial transcripts are free and available at Campus Pipeline (https://mycp.ivytech.edu)

My check or money order, payable to Ivy Tech Community College, is enclosed.

Charge my credit card. VISA MasterCard Discover Exp. Date

Card number

Cardholder Name (as it appears on card)

Student signature ____________________________________________________ Date _______________________
Form must be signed, not typed, to be official.

The Family Educational Rights to Privacy Act of 1974 prohibits the release of a student’s confidential information
to a third party without that student’s written consent.

Ivy Tech Community College is an Equal Opportunity / Affirmative Action State College

FOR OFFICE USE ONLY
Date received Date sent Payment received