Verification Request Form
Eastern
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
Fax# 217-581-3412