Enrollment Verification Form

Clark University
Registrar's Office
950 Main Street
Worcester MA 01610

STUDENT NAME_______________________________________________________________

CLARK ID#_________________________ DATE OF BIRTH_______________________________

Anticipated Date of Graduation______________________

SIGNATURE____________________________________________

DAYTIME PHONE NUMBER_______________________________

_______________________________________________________________________________________________________________________________________

Verification of the following semesters:

__________________________________________________________________
(We are only authorized to establish verification for prior or present attendance.)

This form may be printed and sent to the Registrar's Office or faxed to 508-793-7548. We will also accept email requests for verification at the following address: registrar@clarku.edu.

**Address to be sent to: 

                            NAME:         _____________________________________________

                            ADDRESS:   _____________________________________________

                                                _____________________________________________

        OR

FAX letter to:       NAME:          _____________________________________________

                            FAX #:          _____________________________________________
        OR

Hold letter for pick up on         ____________
                                                      (date) 

**IMPORTANT: If we are mailing directly to an insurance company, you must indicate the SUBSCRIBER'S NAME & ID#: 

                            SUBSCRIBER NAME:    _______________________________________

                            SUBSCRIBER ID # :       _______________________________________

Please allow two business days to process request