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Are you currently enrolled?                                      If not, last date attended?
Campus last attended?        Jackson County Campus       Jefferson Davis Campus             Perkinston Campus
                             George County Center        Keesler Center                     West Harrison County Center
                             Community Campus/Advanced Manufacturing and Technology Center

Were you enrolled prior to Fall 1979?  Yes                                      No
Birth Date:                                                                                                       Social Security Number:
Send Transcript to:
(Please print plainly)

Number of copies to above address                     (or)      Will pick up
Hold for current semester grades                      (or)      Send immediately
Please print current name
Phone number
Former or Maiden Name
Please list any other name(s) under which you might have attended:

I understand that, pursuant to rights contained in the Family Education Rights and Privacy Act of1974, any information
released to the above institution or individual will not be released to any other party without the written consent of the above named

I have been given the opportunity to challenge the contents of my school records to insure that the school records are not
inaccurate, misleading or otherwise in violation of my privacy or other rights and have been provided an opportunity for the
correction or deletion of any such inaccurate, misleading, or otherwise inappropriate data contained therein.


Signed:                                                                                                                                      Date:

Date Issued:                                                                               Paid:

                                                                               PLEASE READ CAREFULLY!
 If your record has been encumbered by financial indebtedness or admission requirements have not been met, no transcript can be issued until
 the obligation has been cleared.

 High School transcripts CANNOT BE RELEASED by this office. Please contact your high school.

 TRANSCRIPTS FROM OTHER COLLEGES or UNIVERSITIES that have been sent to our office for our files CANNOT BE COPIED. Additional
 copies must be obtained directly from the schools.

 Students’ records are confidential and transcripts are issued only at the written request of the student.

    Community                     Jackson County                   Jefferson Davis                   Keesler AFB                    West Harrison                      Perkinston        George County
       Campus                          Campus                             Campus                            Center                        County Center                        Campus              Center
      Advanced                    Admissions/Records                Admissions/Records                 Admissions/Records               Admissions/Records                 Admissions/Records  Admissions/Records
    Manufacturing &                     Office                             Office                           Office                           Office                             Office              Office
   Technology Center                      POB 100                      2226 Switzer Road                     POB 5008                       21500 B Street                     POB 548             POB 77
    10298 Express Drive               Gautier, MS 39553                Gulfport, MS 39507                 Biloxi, MS 39534               Long Beach, MS 39560                Perkinston, MS 39573             Lucedale, MS 39452
     Gulfport, MS 39503                 228/497-7639                     228/896-2500                      228/432-7198                     228/868-6057                        601/928-6206                    601/947-4201
       228/897-4360                   Fax: 228/497-7873               Fax: 228/897-3921                  Fax: 228/435-1542               Fax: 228/868-6060                   Fax: 601/928-6345               Fax: 601/947-4899
     Fax: 228/897-4375
                                                                                                                                                                                                                   SSADM10 (R 6/09)

Mississippi Gulf Coast Community College is an Equal Opportunity Employer and welcomes students and employees without regard to race, color, religion, national origin, sex, age or qualified disability. For further information, contact
the Equal Opportunity Officer at a Mississippi Gulf Coast Community College Center, Campus, or the Central Office. Compliance is coordinated by the Vice President for Administration and Finance, Perkinston Campus, P. O. Box 609,
Perkinston, Mississippi 39573, telephone number 601-928-5211.