ENROLLMENT VERIFICATION REQUEST:

ENROLLMENT VERIFICATION REQUEST:

OFFICE OF THE REGISTRAR 221 S QUARTERLINE ROAD, MUSKEGON, MI 49442 EMAIL: OFFICEOFTHEREGISTRAR@MUSKEGONCC.EDU OFFICE TELEPHONE: 231-777-0310
Student Number
Number
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Semester(s) Being Requested
Last four numbers of Social Security
Date of Request (mm/dd/yyyy)

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Previous Name Used
Any prior name used
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.
Please Choose One
Note: The Family Right and Privacy Act of 1974 prohibits the release of student records to a third party without the students written consent.
Recipient Name
Fax to
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Signature

Clear
Permission to release
Date

MonthDayYear
Date
File Upload

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