TRANSCRIPT/DOCUMENT REQUEST FORM

To submit, mail to Student Records at the address above or fax to 1-510-231-5155.

Today’s Date ______Student ID#______

Name:
Last / First / Middle Initial / Maiden / Previous
Address:
Street / City / State / Zip Code
Phone Number:______
Program/Course Attended:
A & P 1
A & P 2
CT Course
Fluoroscopy
Mammography / Venipuncture
Radiography-Day
Radiography-Eve
Sonography -General
Sonography-Cardiac
Nuclear Medicine / Phlebotomy
IVT & BW
Radiation Therapy
Attended K.P.S.A.H.S.: from: to:
Requested Document(s) / # of Copies
Official Transcript
Unofficial Transcript
Duplicate Certificate
Enrollment Verification
Academic/Clinical Documents / Additional Information:

Signature Date

The Kaiser Permanente School of Allied Health Sciences will not release transcripts from other institutions.

  • The first Transcript /Document is free of charge.
  • Subsequent transcript/documents requested will be charged based on the fees identified on the following page.

Normal Transcript/Document Processing will take up to 5-10 working days.

Rush Transcript/Document Service* if request is received by 12 noon the transcript will be processed by 5pm same day. If received by 3pm M-F documents will be processed by 10am the following business day. Rushed transcripts may be mailed or picked up by the student (Photo ID required). If the student has not picked up the Transcript/Documents in (10) days, they will be mailed to the address provided on the form.

Send Transcript/Documents To:
Name

Dept.
Street
City, State, and Zip Code / Send Transcript/Documents To:
Name

Dept.
Street
City, State, and Zip Code

For Office Use Only

No Charge, 1st Copy ___ Number of copies Requested ( ) x fee = / Total charge to requestor:
Copies will be mailed within (5-10) business days. There is a $10.00 additional charge for RUSH requests
Processed by / Date sent / pickup

Transcript/Document Request

Payment Instructions

  1. Submit a completed Transcript/Document Request Form.
  1. Payment is accepted by credit card only.To pay, copy the hyperlink below into your browser and follow payment instructions.

Certificate Request - $25.00

Transcript Request - $10.00

Document RUSH Fee - $10.00

  1. If an individual other than student is paying for the transcript or document, payer should select “Add Special Instructions to the Seller” and note the name of the student under which the transcript or duplicate certificate will be issued. Screen shots below illustrate this process.

Rev 02/11, 6/11, 7/11, 6/13, 12/15