Enrollment Certification Form

* INDICATES REQUIRED FIELDS

Your name: *
Your name as it was when you were enrolled (leave blank if same):
PUID:*
Your date of birth (MM/DD/YYYY): *
Your college/school:

Dates of enrollment you would like the Office of the Registrar to certify: *	Starting: Year:
	Ending: Year:

Anticipated date of graduation:
Your e-mail address: *
Your telephone number: *
Your Current Address:
Address 1:
Address 2:
Address 3:
City
State:
Zip:
Country:
What kind of certification would you like to receive
Please make a selection: *
Please allow one business day after we receive your request for processing. Course Descriptions Please include below the classes for which you are requesting descriptions. If requesting course descriptions of your full academic history, please allow one business week for processing.
I will pick up this certification.
Mail the certification to the following address:
Name of organization / individual:
Address 1:
Address 2:
Address 3:
City:
State:
Zip:
Country:

For further information, call (765) 494-6165 or send an inquiry via e-mail to certifications@purdue.edu.

Office of the Registrar, Purdue University, West Lafayette, IN 47907
(765) 494-8581, Fax (765) 494-0570, e-mail, registrar@purdue.edu
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Office of the Registrar