REQUEST FOR TRANSCRIPT - DOC

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					                                                   PLEASE NOTE:
                                                   It is the responsibility of the prospective Faculty Member
                                                   requesting the appointment to send the Transcript Request
                                                   to their respective college as there may be a fee associated
                                                   with obtaining the transcript. A copy of the transcript
                                                   request should be given to your department for their files so
REQUEST FOR TRANSCRIPT                             that all parties will know that the transcript has been
                                                   requested and can be included in the appointment packet.


Transcript Requested From
       Names of Institution:

       Address of Institution:



REQUESTER INFORMATION
    Current Name:
    Name on Transcript:

       Current Address:
                Number and Street
                City, State, Zip
                Telephone No.

       Social Security Number:
       Dates of Attendance:
       Degree/Year Awarded:


SIGNATURE: I authorize the release of my academic records to the individual/institution
named below:

       Signed:                                                           Date:
                                                                         Date:
       Faculty Appointment in the MUSC Department of:



Destination: Please send this official transcript to:

Dean’s Office, College of Medicine                 Attn: Cathy Martin
601 Clinical Science Building                             Tel: (843) 792-5374
Medical University of South Carolina                      Fax: (843) 792-2967
P.O. Box 250617, 96 Jonathan Lucas Street
Charleston, SC 29425

Rev: 9/2007

				
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posted:11/9/2012
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