Third-Party Pick-Up Authorization

Use this form to allow a third-party to pick up a document.

Instructions:

** A form must be completed for each separate document to be picked up and is a one-time authorization***

  1. Student completes all information requested below (including signature – electronic signatures are not accepted).
  2. A copy of the student’s photo id must be submitted with this form (driver’s license, passport, etc) to confirm the student’s identity.
  3. Third-party should bring this form and a photo ID to the Penguin Service Center in Meshel Hall, 2nd floor.

Student Information:

Student Name:

Date of Birth:

Banner ID # or Last four of SSN:

 

Document to be released (check only one). A signed third-party authorization form must be completed for each type of document.

Document Type

Additional information needed to place order:

 

Unofficial Transcript (free)

Must have student’s name, birthdate, and YSU ID # or Full SSN

 

Official Rush Transcript ($12)

Must have student’s name, birthdate, and YSU ID # or Full SSN

 

Enrollment Verification

 

Replacement Diploma

Replacement diploma form & payment must be submitted.

 

Other:

 

Authorized Third-Party to pick up document:

Full Name:

Person picking up document must present photo ID in order for the document to be released.

 

I authorize Youngstown State University to release the document indicated above to the third-party individual named. I understand this is a one-time authorization.

Student Signature:

Date:

Signature Required - any form submitted without a written signature will be returned

 

The third-party should bring this completed form, a copy of the student’s ID (driver’s license, passport, etc.), and his or her own photo ID to the Penguin Service Center in Meshel Hall, 2nd floor. Please call 330-941-6000 if you have any questions.

 

PSC Use Only:

Confirm:

Student signature _______ Student ID ________ Third-party ID _________ Enter in SPCMNT ________

For Rush Transcript & Replacement Diploma staple to form. All other requests distribute to Records mail.