Transcript Request Form

Student's Name (Maiden, if applicable) *

First

Last

Your Email Address *

Please use an email address that is checked frequently, in case there are questions about your order.

Your Phone Number *

Address *

Please include the student's FULL address (street, city, state, zip)

Graduation Year *

TRANSCRIPT INFORMATION

How many transcripts do you wish to order? *

Up to 4 transcripts may be ordered on this form.

I would like the Transcript sent via: *

Mail
Email

Select one. If you select both, then you must pay for two transcripts.

Name of College or other Institution to which Transcript should be sent *

If you are a parent or graduate and wish to order a transcript for yourself, enter your name here. NOTE: PARENTS AND/OR GRADUATES MUST ORDER A MAILED TRANSCRIPT. MDHSA only emails transcripts to colleges or other educational institutions.

Address to which Transcript should be mailed *

Address Line 1

Address Line 2

City

State

Zip Code

Email address to which Transcript should be sent *

NOTE: In order to avoid having to order/pay for an additional transcript, please make certain the college/institution will accept an official transcript from MDHSA by email.

I would like Transcript #2 sent via: *

Mail
Email

Select one. If you select both, then you must pay for two transcripts.

Name of College or other Institution to which Transcript #2 should be sent *

If you are a parent or graduate and wish to order a transcript for yourself, enter your name here. NOTE: PARENTS AND/OR GRADUATES MUST ORDER A MAILED TRANSCRIPT. MDHSA only emails transcripts to colleges or other educational institutions.

Address to which Transcript #2 should be mailed *

Address Line 1

Address Line 2

City

State

Zip Code

Email address to which Transcript #2 should be sent *

In order to avoid having to order/pay for an additional transcript, please make certain the college/institution will accept an official transcript from MDHSA by email.

I would like Transcript #3 sent via: *

Mail
Email

Select one. If you select both, then you must pay for two transcripts.

Name of College or other Institution to which Transcript #3 should be sent *

If you are a parent or graduate and wish to order a transcript for yourself, enter your name here. NOTE: PARENTS AND/OR GRADUATES MUST ORDER A MAILED TRANSCRIPT. MDHSA only emails transcripts to colleges or other educational institutions.

Address to which Transcript #3 should be mailed *

Address Line 1

Address Line 2

City

State

Zip Code

Email address to which Transcript #3 should be sent *

In order to avoid having to order/pay for an additional transcript, please make certain the college/institution will accept an official transcript from MDHSA by email.

I would like Transcript #4 sent via: *

Mail
Email

Select one. If you select both, then you must pay for two transcripts.

Name of College or other Institution to which Transcript #4 should be sent *

If you are a parent or graduate and wish to order a transcript for yourself, enter your name here. NOTE: PARENTS AND/OR GRADUATES MUST ORDER A MAILED TRANSCRIPT. MDHSA only emails transcripts to colleges or other educational institutions.

Address to which Transcript #4 should be mailed *

Address Line 1

Address Line 2

City

State

Zip Code

Email address to which Transcript #4 should be sent *

In order to avoid having to order/pay for an additional transcript, please make certain the college/institution will accept an official transcript from MDHSA by email.

Transcript Request Fees *

1 transcript ordered - $5.00
2 transcripts ordered - $10.00
3 transcripts ordered - $15.00
4 transcripts ordered - $20.00

Total

$0.00

OPTION 1: PRINTABLE TRANSCRIPT REQUEST TO BE MAILED WITH CHECK OR MONEY ORDER

OPTION 2: ONLINE FORM
By completing the form below and submitting payment, you are authorizing MDHSA to release your records to the listed institutions.

TRANSCRIPT INFORMATION

OPTION 1: PRINTABLE TRANSCRIPT REQUEST TO BE MAILED WITH CHECK OR MONEY ORDER

OPTION 2: ONLINE FORM By completing the form below and submitting payment, you are authorizing MDHSA to release your records to the listed institutions.

TRANSCRIPT INFORMATION

OPTION 2: ONLINE FORM
By completing the form below and submitting payment, you are authorizing MDHSA to release your records to the listed institutions.