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: ______________________                  Anticipated Month/Year of Graduation: ________________________

Degree Received: ____________________                                      Date of Degree: ______________________________

Check Here   ______    If you want your SOCIAL SECURITY NUMBER printed on the Verification
Check Here   ______    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: ___________________