C:\Users\fzaleski.PBMC\Pictures\School of Radiology logo cmyk.jpg Administrative and Classroom Location: 4 West Main Street, Lower Level Riverhead, New York 11901 Office #: (631) 548 Ð 6183 TRANSCRIPT REQUEST FORM . It is the policy of Peconic Bay School of Radiologic Technology to adhere to the Federal ÒRight to Privacy ActÓ in keeping all studentsÕ records in the strictest confidence. . Each studentÕs academic and clinical records shall be kept on file at Peconic Bay School of Radiologic Technology and shall not be released to other institutions without the written consent of the student in question. . A form should be completed for each transcript requested. . A copy of the state driverÕs license should be attached. ___________________________________________________________________________________ (Last Name) (First Name) (MI) ___________________________________________________________________________________ (Name While Attending Peconic Bay School of Radiologic Technology) Year of Graduation: _________ Last Four of your SSN: __________ Date of Birth: _________________ Print Name: _____________________________________________________________________________________ GraduateÕs Current Address: _____________________________________________________________ _____________________________________________________________________________________ GraduateÕs Signature: ___________________________________________________________________ Date of Signature: _____________________________________________________________________ Method of Payment & Processing: a) Check made payable to ÒPeconic Bay Medical CenterÓ for $10.00: ______________ b) Credit Card Information: Master Card or Visa `or American Express or Discover # ________________________________________ Exp. Date: ___________ Security Code: ___________ c) Cash $10.00 __________________ School Secretary Signature: _________________________________ Processed on: _________________