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Student Signature Date Release of student information without student written request to a third party is prohibited by the Family Educational Right Privacy Act 1974 Receipt Balance Sent Picked Up Date and Time Money Order or Cashier s check ONLY Please make all money orders payable to SCUSOMA 3460 Wilshire Blvd. 00 20. 00 10. 00 Current 20. 00 Withdrawn or Graduate 50. 00 2. 00/ per page 30. 00 50 Duplicate To be sent to Another College/University CA Board for License Exam Other Specify...

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