Transcript Consetr Artrorization @s ://www.strder$cleminglouse.org/secwe_arealTranscript/print*r...

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Print consent Transcript Order Number: 5132813
form

Gonsent to Release lnformation from Education Records

The undersigned individual authorizes

COLLEGE OF SOUTHERN NEVADA

to release the official transcript of his/her education recorde to the individuals and/or oqanizations listed below and
agrees to the charges on his/her credit card resuiting from this order (whiclt will appear on his/her credit card statenent as
"College Transcript).
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4505 S MARYLAI.D PARKT,I,{Y
BOX451021
LAS VEGAS, NV 8S1 54.1021

Student Nane: JASMINE FANTASIA BROWT{ Authorized for Order Nunben 5t32813

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Date

ln order to cornplete your transcript order, you nnrst faX email or rnail a signed copy of this @nsent form to the
Clearinghorse. DO NOT RETURN THIS FORM TO THE SCHOOL lMren we receive your consent form, we will send you
an ernail confinnation within one hour of receipt during nonral business hours (M-F, 95 ET). We will not confirm receipt of
consent form over the telephone.

IMPORTANT: lf we do not receive your consent form within 30 calendar days ftom the date you subffied your request,
your orderwill be canceled and you rlill not be charged.

The lnfurmdion contairFd h this fansmissbn may contah prMleged a'd confdental intu malion. t is intended only for the use of the person(s) named
above and fie l{alional Stderlt Clearinshouse. tryql at€ nd the inten<bd recipieril, you are }ereby noffed that arry rcvierv, dbsemination, distribution, or
dudinfon of thb communi:atbn is sficfy prdribited. f yar are not lhe inbnded r€cipier{ please desfoy a[ copies of fte odginal messqe.

Fax to: 1-703-742-4238 (ltulpoRTANT, remember to dial {-703 first)

Ormail to: National StudentGlearinghouse, 2300 Dulles Station Boulevard, Suite 300, Hemdon, VA20171
Or email scanned copy of sigred consentto: transcripb@studentclearinEhouse.orq

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