UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY



UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY

NEW JERSEY MEDICAL SCHOOL

Registrar’ Office

Request For Degree Certification At NJMS

DATE DEGREE RECEIVED _________ SOCIAL SECURITY ____-____-____ DOB ___________

NAME_______________________________________________________________________________

(LAST) (FIRST) (MIDDLE)

NAME________________________________________________________________________

(Name under which you attended if different)

I would like to request a letter stating that I received a degree from NJMS sent to:

______________________________________________________________________________________

(NAME)

______________________________________________________________________________________

(STREET)

______________________________________________________________________________________

(CITY) (STATE) (ZIP CODE)

___________________________________ ____________________________________

SIGNATURE DATE

If you would like a certification letter sent to your address, please indicate address below.

______________________________________________________________________________________

(NAME)

______________________________________________________________________________________

(STREET)

______________________________________________________________________________________

(CITY) (STATE) (ZIP CODE)

___________________________________ ____________________________________

SIGNATURE DATE

Please return to:

University of Medicine and Dentistry of New Jersey

New Jersey Medical School

Registrar’s Office MSB B-640

185 South Orange Avenue

P.O. Box 1709

Newark, NJ 07101-1709

OR FAX TO: 973-972-6930

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