GRADUATION APPLICATION FOR FORMER MTC STUDENTS

*1.

Student

First Name
Last Name

*2.	Desired Area of Study/Learning Program at MTC

*3.	Please provide the names of the colleges that you most recently attended

	By submitting this agreement you grant MTC permission to: Reactivate your record if needed Update your address and email if it has changed Change your learning program and/or catalog year to one that allows you to graduate if you have not met the requirements in the MTC area of study/learning program indicated above Request copies of transcripts from other colleges you have attended Evaluate transcript(s) and transfer applicable credit to complete your degree

4.

Please type your name as it should appear on your diploma or certificate (legal name only; no titles; indicate punctuation). If this differs from what is in your current MTC records, you will be contacted to complete the name change process.

First Name
Middle
Last Name
Full Legal Name
List any former names
Date of Birth	Month	Day	Year (YYYY)
Mailing Address
State
Zip Code
Phone
Email

*5.	May we send confidential student information to the email address noted above?

	Yes No

*6.

FERPA Statement

FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. In accordance with FERPA, it is the policy of MTC to withhold certain educational records unless the student provides consent to disclose information. The purpose of this form is to provide consent to MTC as required by FERPA.

By checking "Yes" and clicking the submit button below, I hereby understand and authorize MTC to perform a credit evaluation of my classes at MTC as well as classes completed at the above-noted college(s) to award a degree, diploma, or certificate if I am eligible to graduate.
This release form is effective from the date of the submission and consent remains in effect until receipt of the written revocation.

Yes

	For additional information regarding Reverse Transfer, please contact: Permelia Luongo, luongop@midlandstech.edu

GRADUATION APPLICATION FOR FORMER MTC STUDENTS - Reverse Transfer