Enrollment Verification Request

Student ID:

Campus Box:

First Name:

Middle Initial:

Last Name:

Phone Number:

Enrollment Information

Please verify the following information:

Enrollment Status (full-time, part-time) for the current term

Enrollment status for all terms attended

Anticipated date of graduation

For insurance purposes

If for insurance purposes, include:

Policy Holder Name:

Policy Number:

Please mail verification of my enrollment to the following address:

Company Name:

Attention:

Address:

City:

State/Province:

Zip/Postal Code:

or FAX my verification to:

Company Name:

Attention:

Fax Number: