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CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA Registrars Office
Cashiers
Receipt #
FOR OFFICE USE ONLY Records Svc Ind
Initials Date
TRANSCRIPT REQUEST FORM
Payment for transcript(s) is required prior to submitting request to the Registrars Office. All outstanding fees owed to the university must be paid before your transcript order can be processed.
Name
Last No. & Street
First City State
MI
BroncoNumber
(or SSN if BroncoNumber unknown)
Present Address Date of Birth
Zip Code
Contact Phone No. Major
(MM/DD/YYYY)
E-mail
If your records are under a different name, specify: Approximate First Quarter/Year at CPP? Approximate Last Quarter/Year at CPP? Check all that apply below: Process Now Other
Specify:
Fall Fall
Winter Winter
Spring Spring
Summer Summer
(Year)
Hold Until: Grade change processed
Specify Course(s):
Extension Classes Taken
(Cal Poly Ext. Univ. Kellogg West)
Total # of extension classes: Specify:
Term / Year Term / Year Term / Year
Please Note: Holds on a students record will delay processing.
Repeated course processed
Specify Course(s):
Degree posted End of quarter
(Allow three weeks after quarter ends.)
Cal State Teach Submitting your request in-person at: Registrars Office, CLA Bldg. 98-2 Cal Poly Pomona 3801 W. Temple Ave. Pomona, CA 91768
nd
Transcript Fee $6 x
# Transcripts Ordered =
Total Paid
(Make check/money orders payable to Cal Poly Pomona)
floor
Number of copies to be mailed: Number of copies to be picked-up:
(Photo ID Required for pick-up)
Signature:
SIGN AFTER PRINTING
Date:
If transcripts are to be mailed to more than one address, please complete an additional window insert below for each address:
---------------------------------------------------------------------------------------Name
Last First MI
BroncoNumber
Print clearly the name and address where transcript is to be sent for direct mailing. If no address is provided, transcript will be sent to the address given above.
FOR OFFICE USE ONLY
Mail Pick-Up
Rev. 07/2012