Northern Arizona University

APPLICATION ACADEMIC RECORD REQUEST FORM

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TO THE APPLICANT: Complete the information below and send this form to the registrar of each college and university you have attended. Request one copy of your official academic record in a SEALED envelope. When you receive the completed form and academic records in a SEALED envelope, include it UNOPENED with the materials you submit with your application.

DO NOT OPEN THE ENVELOPE WHEN IT IS RETURNED TO YOU BY THE REGISTRAR.

Last Name_________________________ First Name _________________

Middle_______

Current address ____________________________________________________________

____________________________________________________________

Student Id # _________________

Name of college or university

_________________________________________________

School attended within university

_______________________________________________

Dates of enrollment: from _______ to ________

Degree, major, and year

_______________________________________________________

If attended under a name other than above, give other name:

____________________________

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TO THE REGISTRAR: The person named here is applying for admission into the Department of Dental Hygiene at Northern Arizona University. We appreciate your cooperation in our self-managed application process. Please attach a copy of the student's academic record to this form and mail to the APPLICANT in a SEALED envelope. The applicant, will submit it UNOPENED to the Department of Dental Hygiene at Northern Arizona University.

___________________________________	__________________
Registrar's signature	Date

REGISTRAR'S
Official Seal