Verification Request Form

Eastern Illinois University

 

Student Name (print): ______________________________________________

 

Student’s Signature: _______________________________________________

Social Security Number or E-Number: _________________________________

 

This letter should indicate (check appropriate choice below):

 

Loan Deferment: _____                                            Good Student Discount: _____

 

Full-Time attendance:                                                Pre-Registration:                 

Specify which semester & year: ________            Specify which semester & year: ________

 

Other (explain):  _____________________________________________________________

                            

                           _____________________________________________________________

 

How would you like your verification letter delivered?

 

Pick up in Office of the Registrar: ______

 

or:

 

Complete address for mailing:

 

Name line 1: ________________________________________________________________

 

Name line 2: ________________________________________________________________

 

Street Address: ______________________________________________________________

 

City, State & Zip Code: _______________________________________________________

 

or:

 

Faxed to attention of or company name: __________________________________________

 

Fax number (including area code): _____________________________________________

 

Return completed and signed form to:

 

Office of the Registrar

Eastern Illinois University

600 Lincoln Ave.

Charleston,  IL  61920-3099

Fax# 217-581-3412