Important Notice: This form is not intended to be used for transcript requests or requests for diploma copies.

If you need to request transcripts, please visit our Transcript Request page for further instructions. If you need a replacement diploma, please visit our Diploma Replacement Request page.

Personal Information Request

Name*
First name * Last name *
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Phone LSQ
Are You Requesting Information on Behalf of Another Individual?*
- Yes (Please complete the information in the next seciont)
- No
Individual's Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Type of Request*
Method of Access Preferred*
Comments
Gurnick Academy reserves the right to refuse requests, in part or in whole, to the extent permitted by law, if we are unable to verify your identity.
Consent*
I agree to the privacy policy.
By clicking this box, I hereby certify that the information entered into this form is complete, accurate, and up-to-date and that I am the subject requesting the information. I understand that it may be necessary for Gurnick Academy of Medical Arts to verify my identity and additional information may be requested for this purpose. I declare under penalty of perjury that I am the individual whose personal information is the subject of the request.
Comments
This field is for validation purposes and should be left unchanged.

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Individual's Information