I WOULD LIKE TO REQUEST A COPY OF THE FOLLOWING (PLEASE CHECK



Duplin County Schools

P. O. Box 128

Kenansville, NC 28349

Attn: Student Services

I WOULD LIKE TO REQUEST A COPY OF THE FOLLOWING (PLEASE CHECK THE APPROPRIATE ITEM):

COST: $6.00 for 1st copy; $3.00 for each additional copy

_____ TRANSCRIPT

• IMMUNIZATION RECORDS

• SAT SCORES

_____ ALL SCHOOL RECORDS

_____ LETTER VERIFYING GRADUATION

_____ OTHER (PLEASE LIST)

____________________________________________

FULL NAME (USE MAIDEN NAME IF APPLICABLE):

________________________________________________________________

DATE OF BIRTH: ___________________ NCDL _____________________

SOCIAL SECURITY #: _____________________________

NAME OF LAST DUPLIN COUNTY SCHOOL ATTENDED:

__________________________________________________

LAST CALENDAR YEAR OF ATTENDANCE: _________

or

YEAR OF GRADUATION: ____________

PLEASE RELEASE THE REQUESTED INFORMATION TO THE PERSON BELOW OR MAIL TO THE ADDRESS BELOW:

Telephone number: _______________________

Number of copy(s) ________

_______________________________________

Signature

FOR OFFICE USE ONLY

Paid by: Cash _________ Check ________ Money Order __________

Date Received: _____________ Date Mailed: _______________

Date Picked: _______________ Date Faxed: ________________

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