Alumni Verification Request Form

Date Date / MM / DD YYYY
Student Full Name Student Full Name First Middle Last
Maiden/Other Name (if you attended under a different name)
Year of Graduation
Email Address
Phone Number Phone Number - ### - ### ####
Fax Number (if applicable) Fax Number (if applicable) - ### - ### ####
I need a

I need a Form completed (Requires signed release. Please attach below). My final transcript (Requires signed release. Please attach below). Certified copy of my diploma (If you graduated before 2005 you must attach a scanned copy below). Requires signed release (please attach below). Medical School Performance Evaluation (if available).
When complete, please send to

When complete, please send to Myself State Board/Credentialing Service/Medical Staff Office
If mailed, address to mail to If mailed, address to mail to
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Academic Record Release Form

Attach Files
Attachment Upload #1

Attach Files
Attachment Upload #2

Attach Files
Attachment Upload #3

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Comments
Please Note

If you have problems uploading any documents, please email them directly to medverify@vanderbilt.edu and put your full name in the subject line.