Enrollment Verification Request – Paul D. Camp Community College

Complete all sections of this form. Select your delivery preference, indicate what information you need, and sign at the bottom. Click Print to PDF when finished and submit the PDF to the Enrollment Services office.

In accordance with the "Family Education Rights and Privacy Act of 1974" Public Law 93-380 (Education Amendment of 1974), enrollment verifications cannot be released without a written request and signature from the student, except to certain authorized college officials.

NOTE: Please allow 3 – 5 business days for your request to be processed. Please fill in each section completely. Third party requests can be fulfilled through the National Student Clearinghouse.

Fields marked with an asterisk are required.

Student Details

Name

Emplid

Address

City

State

Zip

Phone

VCCS Email

Enrollment Verification Details

I will pick up my enrollment verification.

Please mail my enrollment verification to me at the address above.

Please mail my enrollment verification to the following address:

Enrollment Information

Enrollment verifications include full/part-time status, dates of attendance, and credit hours. If you require additional information, please check all that apply:

GPA

Program of Study

Anticipated Graduation Date (You must have a declared major)

Reason for requesting enrollment verification:

Semester Information

I am requesting an enrollment verification for:

Current Semester

Next Semester

Past Semester, specify term(s) and year(s):

Authorization

I hereby authorize Paul D. Camp Community College to release my student information as indicated above.

Student Signature

Date

Processed by:

Date:

Ready for Pick-Up — Date: Time: