Name: _______________________________________________________________

Year: _____________________________ Class: _____________________________

Address: _____________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Date: _____________________________

Choose One:

___ I will pick up letter from Registrar's Office

___ Please send to my mail box ____________
                                                       (box #)

___ Please mail a letter of verification to:

_________________________________________________
Individual and/or Department

_________________________________________________
Institution

_________________________________________________
Street Address

_________________________________________________
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