Registrar Request Form

Registrar Request Form

Do you have an attachment that is required?*

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Attachment

Please be sure to have the document ready. At the end of this form you will be asked to add the PDF as an attachment.

Form Request*

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Personal Information

First Name*

Last Name*

Student Email Address*

Name When Attending

Banner ID/SSN*

Date of Birth*

Phone Number*

Phone

Campus*

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Program*

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Degree*

Select or enter value

Terms to Certify

e.g. Summer 2023, Summer 2022-Spring 2023

Status

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Start Date

End Date

Matriculation Date

Estimated Year Degree Awarded

(e.g. 2022)

Last ACT 48 Submission*

*Date or Term and Year

PA Dept of Ed/Prof Personnel ID (AUN NO)*

May be found on pde.state.pa.us

Hold Transcript until the current term’s grades are posted

Copies*

Copies

With multiple requests, please use the "Special Request" field for the additional entries to send the transcripts to.

Special Request

I am authorizing the office of the Registrar at PCOM to send my information to a 3rd party.*

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Delivery Information

Delivery Options*

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Recipient Name*

Fax Warning:

I understand that by faxing this form I will be compromising my confidentiality and release PCOM from any liability that may arise.

Recipient Fax Number*

Phone

Recipient Email Address*

Recipient Street Address*

Recipient City*

Recipient State*

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Recipient ZIP Code*

Attach Document

File Upload*

Drag and drop files here or

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