Transcript Request Form – Breining Institute

Instructions *

Section 1. Authorization Information

Transcripts may be ordered by the student.

In order to comply with the Family Educational Rights and Privacy Act of 1974 (FERPA), all transcript orders require authorization.

Breining Institute provides the following procedure for authorizing online transcript orders, if:

– You attended Breining Institute any time from 1986 to the present;
– The billing name on the credit card you use to pay for this order matches both the student name on this order and the student name in our records; and,
– The fields in this order including the last four digits of your Social Security Number, Date of Birth, and Signature match the information in our records

Checking student records is a process that occurs after your order has been entered, thus, we cannot tell you definitively at the time of ordering that your order will qualify for Automatic Authorization. If we successfully authorize your order, we will send the transcripts to your designated party within ten days of receiving a complete order. If we are unable to automatically authorize your order, we will send you an Authorization Form that you must then sign and return via fax or mail before your order can be completed.

If you do not wish to submit your Transcript Request online, you may print and complete this form, and then send to us by email, facsimile or postal mail.

The Office of the Registrar takes responsibility for handling transcript requests in a prompt and efficient manner. However, we are not responsible for mishandling by the U.S. Post Office or the receiving school or agency.

Student Info *

Section 2: Student Information

Full Name: *

Other names (if applicable) that you may have used while enrolled with Breining Institute

Last four digits of your Social Security Number *

Date of Birth *

Current Address *

Country

City

State

Zip code

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Attendance Info *

Section 3: Attendance Information

Which year(s) did you attend and/or graduate from Breining Institute? *

Breining Institute program(s) from which you graduated and/or attended. Please select all that apply. *

FAST TRACK Program - 17 units

Addiction Studies Certificate (ASC) Program - 45 units

Associate of Arts in Addictive Disorders Degree Program

Bachelor of Arts in Addictive Disorders Degree Program

Master of Arts in Addictive Disorders Degree Program

Doctor in Addictive Disorders (Dr.AD) Degree Program

Where to send *

Section 4: Where do you want these transcripts sent?

We will send one set of transcripts to the individual or institution you identify within this section.
If a paper transcript is requested, we will send it by regular First Class mail using the U.S. Postal Service (USPS), to the mailing address you provide below.
If an electronic PDF copy of transcripts is requested, it is only available to be sent directly to the student. If you, the student, would like to order an electronic PDF copy of your transcripts, you may select that option, below.

Please identify whether you are ordering a paper or an electronic PDF copy of your transcripts. *

I am ordering an electronic PDF copy of my transcripts to be emailed to me

I am ordering a paper copy of my transcripts to be mailed by USPS

Email address to send PDF transcript to Student

If the Student is ordering a personal copy of the PDF transcript, it will be emailed to the email address that you input below.

Confirm email address

If you are ordering a paper transcript, provide the mailing address below.

Name of the person

This is the person or institution that will be mailed the transcript. If it is you, please include your full name. If it is an institution, it is a good idea to have it addressed to an individual.

Name of the institution, if applicable

Address

City, State, ZIP Code

Payment Info

Section 5: Order

You are ordering one set of transcripts. *

PLEASE NOTE: If you need additional transcripts, you will need to submit a different order for each different address.

$75: I am ordering ONE (1) official, sealed transcript be sent via regular First Class USPS mail to the person and/or institution identified in Section 4.

$75: I am ordering ONE (1) electronic PDF copy of my transcripts be sent to me personally, to the email address provided in Section 4.

Section 6: Credit Card and Payment Information

You give permission to and authorize Breining Institute to charge the total amount of seventy-five dollars ($75.00) for the item selected in Section 5, above, to the following credit card:

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Full Name on Credit Card: *

Credit Card Expiration Date *

Signature

Please carefully use this space to sign your name, which must match the signature we have on record in your student file.

Reset Signature

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