Transfer Back - Lake Land College

In support of the Transfer Back - A Credential Partnership with Lake Land College, this serves as a release of your EIU transcript to Lake Land College mailed to: Lake Land College, Admissions & Records, 5001 Lake Land Blvd., Mattoon, IL 61938. There is no charge for transcript delivery for students in this program.

Name Name * First Middle Last
Former/Maiden (if applicable)
EIU Student E#
Date of Birth Date of Birth * / MM / DD YYYY
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address
Phone Phone - ### - ### ####
FERPA Statement:

Under the Family Educational Rights and Privacy Act (FERPA) of 1974, updated January 2009, I understand that my educational records cannot be released without my permission. I authorize the release of my academic records from EIU to Lake Land College, and the release of any additional academic records from Lake Land College to EIU, in order to share student data information between the two institutions without the violation of FERPA. I understand that I have the right to rescind this release agreement of my academic records at any time by notifying the Registrar at Eastern Illinois University.

I understand the FERPA statement and agree to my student records being shared between EIU and Lake Land College for the purpose of credit evaluation. This form also confirms my intention to graduate from Lake Land College if/when I have met the requirements as determined by Lake Land College.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
A copy of this form will be sent with the official transcripts.

Transfer Back - Lake Land College

Transfer Back - Lake Land College

FERPA Statement: