PEMBROKE ACADEMY

209 ACADEMY ROAD,  PEMBROKE, NH  03275-1343

(603)485-7881    FAX (603) 485-1824

                                                Date ____________________________________

I, ______________________________________ give my permission for Pembroke Academy to release any or all of my academic records

to be sent to: (Please note:  official transcripts can only be sent to an educational facility, business, military or organization)

            _____________________________________________________

                        _____________________________________________________

                        _____________________________________________________

                        _____________________________________________________

Class of _____________ (Year of Graduation)

Last name when graduated ___________________________

Date of birth ___________________

Contact number I can be reached at ____________________

Signature: _________________________________________________________

Please include the $2.00 fee (cash, check, or money order) and mail to:

Registrar

Pembroke Academy

209 Academy Road

Pembroke, NH  03275