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Credential Request Form		Counseling and Career Services 816 Chestnut, 304 Founders Hall Lincoln University Jefferson City, MO 65101

CAREER PLACEMENT CREDENTIALS REQUEST In order to expedite your request to have your Career Placement Credentials sent to a prospective employer, please complete the following form. Only one request per form. Please enclose a money order or cashier's check in the amount of $5.00 per prospective employer, if this is not your first request.

NAME:		SSN#:
ADDRESS:
CITY:	STATE:	ZIP:
PHONE:

IS THIS YOUR FIRST REQUEST?

YES

NO

CAREER CREDENTIAL FILE SHOULD BE SENT TO THE FOLLOWING PERSON(S):

NAME/TITLE:

ORGANIZATION:

ADDRESS:

CITY / STATE / ZIP CODE:

TITLE OF POSITION FOR WHICH YOU ARE APPLYING?

SIGNATURE OF STUDENT / ALUMNI

DATE

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* * * * * * * * OFFICE USE ONLY * * * * * * * *

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FREE REQUEST

YES

NO

FEE ENCLOSED

YES

NO

DATE CREDENTIALS MAILED:

AUTHORIZED SIGNATURE: