Final High School Transcript Request

Please reply by July 31, 2011.

In order to complete your enrollment, Rensselaer must receive an official copy of your final high school transcript showing the exact
date of graduation. Please fill out the student information below and submit this form to your guidance counselor. Please print clearly.

Student Information

Last name_______________________________________________________________________________________________________________________First name _________________________________________ Middle _____________________

Date of birth ________ / ________ / ________ Rensselaer Identification Number (RIN) 6 6 ____ ____ ____ ____ ____ ____ ____
MM DD YYYY

Permanent address _________________________________________________________________________________________________________

City ______________________________________________________ State __________________ Zip/Postal code ________ Country _______________

Secondary School Information

(To be filled out by guidance counselor or school official)

Please fill out and return this completed form to Rensselaer no later than July 31, 2011.

High school ____________________________________________________________________________________________________________________

The student named above graduated on ________ / ________ / ___________ (month, day, year all required)
MM DD YYYY

Signature of Guidance Counselor or School Official _________________________________________________________________________________

Please return this completed form, along with the final high school transcript, to

Rensselaer Admissions
Undergraduate Programs
Rensselaer Polytechnic Institute
110 8th Street
Troy, NY 12180-3590

0211 11392 SC