FORMER HIGH SCHOOL OR COLLEGE
TRANSCRIPT REQUEST FORM
Please send my official academic transcript, including any placement test scores to:
ST. JOHNS RIVER STATE COLLEGE
ATTN: ADMISSIONS OFFICE
5001 ST. JOHNS AVENUE
PALATKA, FLORIDA 32177
COLLEGES AND UNIVERSITIES: PLEASE PROVIDE
COURSE DESCRIPTIONS FOR ALL COURSES ON
STUDENT’S ACADEMIC TRANSCRIPT.
If there is any charge for this transcript, or if my transcript cannot be forwarded
immediately, please notify me at the address and phone number listed below:
STUDENT’S NAME: _______________________________________________________
SOCIAL SECURITY NUMBER:_____________________________________________
DATE OF BIRTH:_______________________
STREET ADDRESS:______________________________________________________
CITY, STATE ZIP CODE:__________________________________________________
DAYTIME TELEPHONE NUMBER:______________________________
DATES OF ATTENDANCE:_____________________________________
______________________________________________________________________________
STUDENT’S SIGNATURE DATE
St. Johns River State College, an equal access institution, prohibits discrimination in its employment, programs, activities, policies and procedures
based on race, sex, gender, gender identity, age, color, religion, national origin, ethnicity, disability, pregnancy, sexual orientation, marital status,
genetic information or veteran status. Questions pertaining to education equity, equal access or equal opportunity should be addressed to the
College Title IX Coordinator/Equity Officer: Charles Romer, Room A0173, 5001 St. Johns Avenue, Palatka, FL 32177; (386) 312-4074;
[email protected]. Anonymous reporting is available at SJRstate.edu/report. Inquiries/complaints can be filed with the Title IX
Coordinator/Equity Officer online, in person, via mail, via email or with the US Department of Education, Office of Civil Rights, Atlanta Office,
61 Forsyth St. SW Suite 19T10, Atlanta, GA 30303-8927.
Revised June 2013
