University of Rochester

A copy of this form will be sent to the Center for Academic Support.

This form is intended for undergraduates who do not plan to return the University, but complete course requirements at another college or university.

For graduation with the Class of:

Name: Student ID:

Address:

E-mail: Phone:

Institution(s) attended since leaving the University of Rochester:

I was a member of the Class of and was a candidate for a degree in the
Department of:

I am submitting a check in the amount of $25.00 made payable to the University of Rochester. I agree to complete all outstanding work, and submit an official transcript and course descriptions (if applicable), so that I may receive my degree with the class specified above. Send check to: Center for Academic Support, University of Rochester, Lattimore 312, Rochester, NY 14627.