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Transcript Release Permission Form

To be completed by the applicant.
Note: Check with the institution for any required transcript fee.

Institution Name:____________________________________________

Institution Address: ___________________________________________

Institution City, State, Zip:______________________________________

Office of the Registrar:
I attended your institution from ________ to ________

Please send an official transcript to:
Distance Minnesota
Office of Admission
PO Box 309
Perham, MN 56573

Name:     
Maiden or Previous Name:     
Address:     
City / State / Zip:     
Social Security Number:     
Phone Number:     
Email:     
Signature:

The college is asking you to provide information which includes private information under State and Federal law. The information is optional. However, if you refuse to provide some or all of the optional information, the college may not be able to process your request.

Contact:

Distance Minnesota
P.O. Box 309, Perham, MN 56573
Online Support / 1-800-456-8519
+1.651.556.0596 (international)
TTY: 1.800.627.3529

WoW Award 2007