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*
Please Choose One*

I will pick-up (bring photo identification with you)Please include other documents attachedMail to the recipient listed belowfax with the number listed to the recipient below
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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