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BMHS GUIDANCE DEPARTMENT

TRANSCRIPT REQUEST FORM

This form must be completed in full before any transcripts can be released. Please allow up to ten (10) working days for processing.

_________________________________ _______________________

Student’s Name (last, first) D.O.B

________________________________ __ __ __- __ __- __ __ __ __

Student E-Mail Address Social Security

I Hereby Authorize Brien McMahon Guidance Department to Release the following information:

Transcript and Cumulative Record Data

_ Special Education/Student Services Records (I.E.P., P.P.T. Minutes,

Psychological, Social Work, Speech/Hearing)

Other as specified: Recommendations and Unofficial SAT Scores

*Official scores must be sent by you from www.collegeboard.com

________________________________ __________________________

Signature Year of Graduation

COLLEGE/UNIVERSITY ADDRESS FAX#

Fees per Transcript: __________$2- fax ________ $3- pick up _______ $4 mail = Total_______

Ex 2 fax x $2=$4 2 pickup x $3=$6 Total $10