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
2 digit month, 2 digit day, 4 digit yearDate
Semester(s) Being Requested
Last four numbers of Social Security
Date of Request (mm/dd/yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 or More
Note: The Family Right and Privacy Act of 1974 prohibits the release of student records to a third party without the students written consent.
If pick-up is selected please indicate where you would like to pick up the document
Recipient Name
IF MAILING OR FAXING YOU MUST PROVIDE A NUMBER OR ADDRESS BELOW. WITHOUT THIS YOUR REQUEST WILL BE DENIED.
Fax to
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Signature

Permission to release
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload

Cancelof
Should be Empty: