Transcript Request Form
Return form to: riveramoodylu@nassau.k12.fl.us
School: ____________________________ Year: ____
Student Name: ______________________________________
(Maiden Name if Female): ____________________________
Date of Birth: ______________________________________
Did Student: (check one)
_____ Graduate Date of Graduation: ________
_____ Non-Grad
_____ Adult High School
_____ GED Date Received GED: ________
Needs:
_____ Official Transcript
_____ Student Copy of Transcript
_____ Verification of Graduation
Send To:
_____ I will pick up from 1201 Atlantic Ave., Fernandina Beach, FL 32034
Name: ______________________________________________
Address to be sent to: __________________________________
____________________________________________________
Phone #: ____________________________________________
FAX #: _____________________________________________
Signature: ___________________________________________
I give permission for the Nassau County School Board to release my records to the above address.
The Nassau County School District does not discriminate on the basis of race, color, national origin, gender, age, disability or marital status in its
educational programs, services or activities, or in its hiring or employment practices. For questions or complaints, please call (904) 491-9900.
