SLCC Reverse Transfer Application

Full Legal Name:*

(First, Middle, Last & Suffix if applicable)

SLCC Student ID Number:

(Letter followed by 8 digits)

Program / Major:*

(Example: Associate of General Studies)

By signing this agreement you grant SLCC permission to:

Reactivate your record, if it has been more than two years since you last attended
Update your address and email, if it has changed
Change your program/major and/or catalog term to one that allows you to graduate, if you have not met the requirements in the SLCC area of study indicated above
Evaluate transcript(s) and transfer applicable credit to complete your degree

Please list the college(s) you will be providing official transcripts from: *

Please provide your name as it should appear on the diploma or certificate:*

(name only; no titles; indicate punctuation)

Please list any former names.

Provide full previous name (first, middle, last).

Date of Birth:*

MonthDayYear

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:*

student@example.com

Phone Number*

Please enter a valid phone number.

May we send confidential information to the email address noted above?
Yes No*

FERPA Statement

FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. In accordance with FERPA, it is the policy of SLCC to withhold certain educational records unless the student provides consent to disclose information. The purpose of this form is to provide the consent to SLCC as required by FERPA.

I, the undersigned, hereby understand and authorize SLCC to perform a credit evaluation of my classes at SLCC as well as classes completed at the above noted college(s) to award a degree or certificate, if I am eligible to graduate.

This release does not permit the disclosure of these records to any other persons or entities without my written consent or as permitted by law. This release form is effective from the date of signature below and consent remains in effect until receipt of written revocation.

Signature:*

By signing your name electronically on the Reverse Transfer Application, you agree that your electronic signature is the legal equivalent of your manual signature on this form.

Date:*

For more information please contact: reversetransfer@solacc.edu.