Transcript Request Form
To Be Completed By All Applicants

Please complete this form, detach, and mail separately to your high school(s) or college(s).
Transfer applicants who have fewer than fifteen (15) college credits must submit their high school records in addition to their college transcript.

Date: _______________

Dear Registrar,

At your earliest convenience, Please forward an official transcript of my academic record to:

Karol Marcinkowski University of Medical Sciences
4 Year MD Program in English
108 Village Square, #402
Somers, NY 10589-2305
Tel: +1 (888) 251-6659

Thank you.
Sincerely,

______________________
Student Signature

To assist your high school(s) or college(s) in identifying your records, please supply the following information:

Your Name: ________________________________________________________

Address: __________________________________________________________

City: ______________________ State: _________________ Zip: ______________

Date of Birth: ________________ Social Security Number: ______________________

Date (or expected date) of leaving high school or college: (Month): ________ (Year): _________

If you were formerly known by a different name, please specify:

Name: _____________________________________________________________

Address: ___________________________________________________________

City: ______________________ State: _________________ Zip: ______________