Enrollment Verification Form

Date

Your First Name*

Your Last Name*

Student's First Name*

Student's Last Name

Student ID Number

Email Address

Anticipated Graduation Date (mm/dd/yyyy)

Indicate Current Semester

Current School Year (if already enrolled)

Graduated Year

How will this verification be delivered?

Physical address if verification is to be mail.

Mailing Address Line 2

City:

State / Province / Region:

Postal / Zip Code:

Country:

Fax Number if to be faxed

I authorize Voorhees University to verify all information contained in my academic record and hereby release Voorhees College and its employees from any liability for issuing this information.

I represent that I am the applicant and my typed name below authorizes the same as my signature.

Requestor's Name

Requestor

Guardian

Student

Requestor's Phone Number