enrollment verification request

DEMOGRAPHIC INFORMATION

Student ID Number:       Email:

First Name:       Middle Initial:  A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Y. Z.      Last Name:

Phone: () -

ENROLLMENT INFORMATION

Please include the following in the Verification:

Enrollment Status (full-time, part-time) for the current term

Enrollment Status for all terms attended

Projected Date of Graduation

For Insurance Purposes

If for Insurance purposes, include:

Policy Holder Name: Policy Number:

Please mail a verification of my enrollment to the following address:

Name: Address: City:    State/Province:  AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY AB BC ON    Zip/Postal Code:

or FAX the verification to:

Organization: FAX Number: () -