Request for Enrollment Verification

Request for Enrollment Verification

Sam Houston State University
A Member of The Texas State
University System

Office of the Registrar
Box 2029
Huntsville, Texas
77341-2029

Date:_____/______/______

Anticipated Graduation Date:_____________
(Month/Year)

Policyholder's name: ________________________

Policy number: _____________________________

OR attach a copy of your insurance card

Student SamID/Social Security:____________________________________

Name(PRINT):

________________________
(Last)

____________________
(First)

______________________
(Middle)

__________________________

(Maiden)

Mail To: (Print Clearly Complete Address)

__________________________

Signature:______________________________
(Student signature required)

Phone Number:_________________________

***There is no fee for this service***

***We do not fax enrollment verification forms***

	Sam Houston State University
	A Member of The Texas State University System Office of the Registrar Box 2029 Huntsville, Texas 77341-2029	Office: (936) 294-1038 FAX: (936) 294-4964