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Uconn Verification Enrollment Form
Birth: _____/_____/______
Dates of Attendance:
School (Medical or Dental): ______________________________________
From: ________________________ To: __________________________
Please provide preferred contact information where you may be reached:
Phone: ______________________________ Email: __________________________________________________
I hereby authorize the University of Connecticut to release verification of enrollment and related documents
to the recipient named on this form.
Date:...
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