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Student Enrollment Verification Form

Submit to: Verifications Dept., 65 Davidson Road, Room 200L, Piscataway, NJ 08854-8096, Fax (732)445-5948 Please allow at least 5 working days for the certification to be processed and mailed. Name (Last, First, Middle - Under which currently attending):___________________________________ Name Change (If applicable): _________________________________________________ Home Address

(Street, Town/City, State, Zip Code):

Campus Address:

Home Phone:

Campus Phone:

School: __________ Date of Birth (Optional): ______________ RUTGERS RUID #: _______________________ SOCIAL SECURITY #:_____________________________ Degree Sought: _____________________ Degree Received: ____________________ Check Here ______ Check Here ______ Anticipated Month/Year of Graduation: ____________ Date of Degree: ____________________________

If you want your SOCIAL SECURITY NUMBER printed on the Verification If you want your GPA (Grade Point Average) printed on the Verification

Verifications must be sent directly to the person, agency, or school concerned. Include the full name and address. If you need a copy for your own records, please indicate it on the form and a verification will be mailed to your address. Please PRINT CLEARLY. Please send Verification to:

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Type of Form or Letter to be Sent: _______ Letter of Enrollment _______ Good Student Application (Insurance Discount - Attach company form and provide insurance policy number) _______ Health Insurance (Attach form, if applicable) _______ Other:___________________________________________________________________________________ I hereby authorize the Registrar's Office to release all information as indicated above and/or on the attached form(s).

Student's Signature:______________________________________

Date: ___________________

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