SAMUEL J. TILDEN HIGH SCHOOL
c/o It Takes A Village Academy
5800 Tilden Avenue
Brooklyn, NY 11203

ATTN: DEBRA SYLVESTER

REQUEST FOR OFFICIAL TRANSCRIPT OR VERIFICATION LETTER

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Print this Page and MAIL Completed Form To The Above Address or FAX: (718) 629-6162

THERE IS NO PICKUP SERVICE AVAILABLE / ALL TRANSCRIPTS AND VERIFICATIONS WILL BE MAILED

DATE:___________________________________


NAME AT TIME OF ATTENDANCE:
______________________________________________________
(Maiden name or name change)

Date of Birth: ___________________________________

Dates of Attendance:______________________________TO ________________________________

Year of Graduation: ______________________________


Current Address
________________________________________________

City________________________________________State____________
Zip Code___________________

Telephone Number:__________________________________

Email Address:______________________________________


Name and Address of School/Business to Receive Transcript/Verification:

Name__________________________________________________

Address__________________________________________________

City________________________________________State____________Zip Code________________

Signature: ________________________________________________