Enrollment Verification Request Form

This form may be used for confirmation of enrollment status or verification of graduate degree(s) earned for employment purposes, insurance, international travel letters, etc. If you need confirmation of enrollment status for Loan Deferment purposes, please do not submit this form. You must provide a hard copy Loan Deferment Request Form (obtain form from your student loan servicer) to the Offices for Graduate Education, URMC, 601 Elmwood Avenue, Box 316, Rochester, New York 14642. All enrollment verification requests will be forwarded to the Registrar for Graduate Programs in the School of Medicine and Dentistry.

	Name while attending

	If different
	Last Name

	First Name

	Middle Initial

	Phone Number (required)

	Email Address (required)

	Mailing Address (required)
	Classification (check one)
	Current Graduate Student Graduate Program Alumni

	If Graduate Program Alumni, what was your graduation date? MM/YY

	What enrollment period do you need verified? MM/YY- MM/YY -

	Do you require verification of your pre-doctoral fellowship (stipend, tuition scholarship, health insurance coverage)?
	Yes No

	Mail to: (Please provide Name, Institution and Complete Mailing Address)