Educational History Document

EDUCATIONAL HISTORY DOCUMENT

Student Information

Date of Birth:    Student ID (if applicable):

Primary Phone:    Email:

Parent / Guardian (if student is a minor)

Is the student under 18 years of age? Yes No

Prior Educational Institutions (List most recent first)

Institution 1

Dates Attended: From to

Major / Area of Study:    Cumulative GPA:

Institution 2

Dates Attended: From to

Major / Area of Study:    Cumulative GPA:

Additional Education / Certifications

Disciplinary, Academic Integrity, and Legal Matters

Has the student ever been suspended, expelled, placed on probation, or otherwise disciplined by an educational institution? Yes No

Records Release Authorization

I hereby authorize the release of academic records, transcripts, disciplinary records, and verification of enrollment or awards from any institution I have attended to the educational institution, admissions office, or authorized representative making this request. This authorization applies to records requested for enrollment, evaluation, scholarship consideration, or transfer credit determination.

Does the student authorise release of financial aid or billing records if requested? Yes No

Academic Record Summary

Highest level of education completed: High School Associate Bachelor Master Doctorate Other

Supplemental Information

Certifications and Acknowledgments

By signing below, I certify that the information provided on this Educational History Document is true, correct, and complete to the best of my knowledge. I understand that knowingly making a false statement or omission may result in denial of admission, rescission of an offer, disciplinary action, or other consequences as permitted by institutional policy or applicable law. I authorize educational institutions named herein to release records as necessary to verify the statements above.

I further acknowledge that additional documentation may be requested to substantiate claims made on this form and that processing of my application or request may be delayed pending receipt of such documentation.

Consent to Release for Minors: If the student is under 18, the signature of a parent or legal guardian below constitutes authorization for release of records and the certifications above on behalf of the minor student.

Sign Now