{"id":8665,"date":"2018-08-18T10:04:30","date_gmt":"2018-08-18T17:04:30","guid":{"rendered":"http:\/\/www.breining.edu\/?page_id=8665"},"modified":"2022-07-20T12:42:56","modified_gmt":"2022-07-20T19:42:56","slug":"transcript-request-form","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/higher-education\/transcript-request-form\/","title":{"rendered":"Transcript Request Form"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-98\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-98\" value=\"1776842986\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"98\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Instructions <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2989\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2990\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2990\" class=\"vfb-control-label\">Section 1. Authorization Information<\/label><div class=\"\"><p>Transcripts may be ordered by the student.<\/p>\n<p>In order to comply with the Family Educational Rights and Privacy Act of 1974 (FERPA), all transcript orders require authorization.<\/p>\n<p>Breining Institute provides the following procedure for authorizing online transcript orders, if:<\/p>\n<p>&#8211; You attended Breining Institute any time from 1986 to the present;<br \/>\n&#8211; The billing name on the credit card you use to pay for this order matches both the student name on this order and the student name in our records; and,<br \/>\n&#8211; The fields in this order including the last four digits of your Social Security Number, Date of Birth, and Signature match the information in our records<\/p>\n<p>Checking student records is a process that occurs after your order has been entered, thus, we cannot tell you definitively at the time of ordering that your order will qualify for Automatic Authorization. If we successfully authorize your order, we will send the transcripts to your designated party within ten days of receiving a complete order. If we are unable to automatically authorize your order, we will send you an Authorization Form that you must then sign and return via fax or mail before your order can be completed.<\/p>\n<p>If you do not wish to submit your Transcript Request online, you may print and complete this form, and then send to us by email, facsimile or postal mail.<\/p>\n<p>The Office of the Registrar takes responsibility for handling transcript requests in a prompt and efficient manner. However, we are not responsible for mishandling by the U.S. Post Office or the receiving school or agency.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Student Info <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2991\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 2: Student Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2992\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2993\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2993\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2993\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2993\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2994\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2994\" class=\"vfb-control-label\">Other names (if applicable) that you may have used while enrolled with Breining Institute<\/label><div><input id=\"vfb-field-2994\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2994\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2995\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2995\" class=\"vfb-control-label\">Last four digits of your Social Security Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2995\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2995\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2996\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2996\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2996\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2996\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-address\" id=\"vfbField2997\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2997\" class=\"vfb-control-label\">Current Address <span class=\"vfb-required-asterisk\">*<\/span><\/label><div class=\"vfb-address-block\" id=\"vfb-field-2997\"><div class=\"vfb-form-group\" style=\"\"><input id=\"vfb-field-2997-address-1\" class=\"vfb-form-control vfb-addresspart-address-1\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2997[address-1]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-2997-country\" class=\"vfb-address-label\">Country<\/label><select id=\"vfb-field-2997-country\" class=\"vfb-form-control vfb-addresspart-country\" placeholder=\"\" required=\"required\" name=\"vfb-field-2997[country]\"><option value=\"US\" selected='selected'>United States (US)<\/option><option value=\"GB\">United Kingdom (UK)<\/option><option value=\"CA\">Canada<\/option><option value=\"AU\">Australia<\/option><option value=\"\">---<\/option><option value=\"AF\">Afghanistan<\/option><option value=\"AX\">&#197;land Islands<\/option><option value=\"AL\">Albania<\/option><option value=\"DZ\">Algeria<\/option><option value=\"AD\">Andorra<\/option><option value=\"AO\">Angola<\/option><option value=\"AI\">Anguilla<\/option><option value=\"AQ\">Antarctica<\/option><option value=\"AG\">Antigua and Barbuda<\/option><option value=\"AR\">Argentina<\/option><option value=\"AM\">Armenia<\/option><option value=\"AW\">Aruba<\/option><option value=\"AS\">American Samoa<\/option><option value=\"AT\">Austria<\/option><option value=\"AZ\">Azerbaijan<\/option><option value=\"BS\">Bahamas<\/option><option value=\"BH\">Bahrain<\/option><option value=\"BD\">Bangladesh<\/option><option value=\"BB\">Barbados<\/option><option value=\"BY\">Belarus<\/option><option value=\"BE\">Belgium<\/option><option value=\"PW\">Belau<\/option><option value=\"BZ\">Belize<\/option><option value=\"BJ\">Benin<\/option><option value=\"BM\">Bermuda<\/option><option value=\"BT\">Bhutan<\/option><option value=\"BO\">Bolivia<\/option><option value=\"BQ\">Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\">Bosnia and Herzegovina<\/option><option value=\"BW\">Botswana<\/option><option value=\"BV\">Bouvet Island<\/option><option value=\"BR\">Brazil<\/option><option value=\"IO\">British Indian Ocean Territory<\/option><option value=\"VG\">British Virgin Islands<\/option><option value=\"BN\">Brunei<\/option><option value=\"BG\">Bulgaria<\/option><option value=\"BF\">Burkina Faso<\/option><option value=\"BI\">Burundi<\/option><option value=\"KH\">Cambodia<\/option><option value=\"CM\">Cameroon<\/option><option value=\"CV\">Cape Verde<\/option><option value=\"KY\">Cayman Islands<\/option><option value=\"CF\">Central African Republic<\/option><option value=\"TD\">Chad<\/option><option value=\"CL\">Chile<\/option><option value=\"CN\">China<\/option><option value=\"CX\">Christmas Island<\/option><option value=\"CC\">Cocos (Keeling) Islands<\/option><option value=\"CO\">Colombia<\/option><option value=\"KM\">Comoros<\/option><option value=\"CG\">Congo (Brazzaville)<\/option><option value=\"CD\">Congo (Kinshasa)<\/option><option value=\"CK\">Cook Islands<\/option><option value=\"CR\">Costa Rica<\/option><option value=\"HR\">Croatia<\/option><option value=\"CU\">Cuba<\/option><option value=\"CW\">Cura&Ccedil;ao<\/option><option value=\"CY\">Cyprus<\/option><option value=\"CZ\">Czech Republic<\/option><option value=\"DK\">Denmark<\/option><option value=\"DJ\">Djibouti<\/option><option value=\"DM\">Dominica<\/option><option value=\"DO\">Dominican Republic<\/option><option value=\"EC\">Ecuador<\/option><option value=\"EG\">Egypt<\/option><option value=\"SV\">El Salvador<\/option><option value=\"GQ\">Equatorial Guinea<\/option><option value=\"ER\">Eritrea<\/option><option value=\"EE\">Estonia<\/option><option value=\"ET\">Ethiopia<\/option><option value=\"FK\">Falkland Islands<\/option><option value=\"FO\">Faroe Islands<\/option><option value=\"FJ\">Fiji<\/option><option value=\"FI\">Finland<\/option><option value=\"FR\">France<\/option><option value=\"GF\">French Guiana<\/option><option value=\"PF\">French Polynesia<\/option><option value=\"TF\">French Southern Territories<\/option><option value=\"GA\">Gabon<\/option><option value=\"GM\">Gambia<\/option><option value=\"GE\">Georgia<\/option><option value=\"DE\">Germany<\/option><option value=\"GH\">Ghana<\/option><option value=\"GI\">Gibraltar<\/option><option value=\"GR\">Greece<\/option><option value=\"GL\">Greenland<\/option><option value=\"GD\">Grenada<\/option><option value=\"GP\">Guadeloupe<\/option><option value=\"GT\">Guatemala<\/option><option value=\"GG\">Guernsey<\/option><option value=\"GN\">Guinea<\/option><option value=\"GW\">Guinea-Bissau<\/option><option value=\"GY\">Guyana<\/option><option value=\"HT\">Haiti<\/option><option value=\"HM\">Heard Island and McDonald Islands<\/option><option value=\"HN\">Honduras<\/option><option value=\"HK\">Hong Kong<\/option><option value=\"HU\">Hungary<\/option><option value=\"IS\">Iceland<\/option><option value=\"IN\">India<\/option><option value=\"ID\">Indonesia<\/option><option value=\"IR\">Iran<\/option><option value=\"IQ\">Iraq<\/option><option value=\"IE\">Republic of Ireland<\/option><option value=\"IM\">Isle of Man<\/option><option value=\"IL\">Israel<\/option><option value=\"IT\">Italy<\/option><option value=\"CI\">Ivory Coast<\/option><option value=\"JM\">Jamaica<\/option><option value=\"JP\">Japan<\/option><option value=\"JE\">Jersey<\/option><option value=\"JO\">Jordan<\/option><option value=\"KZ\">Kazakhstan<\/option><option value=\"KE\">Kenya<\/option><option value=\"KI\">Kiribati<\/option><option value=\"KW\">Kuwait<\/option><option value=\"KG\">Kyrgyzstan<\/option><option value=\"LA\">Laos<\/option><option value=\"LV\">Latvia<\/option><option value=\"LB\">Lebanon<\/option><option value=\"LS\">Lesotho<\/option><option value=\"LR\">Liberia<\/option><option value=\"LY\">Libya<\/option><option value=\"LI\">Liechtenstein<\/option><option value=\"LT\">Lithuania<\/option><option value=\"LU\">Luxembourg<\/option><option value=\"MO\">Macao S.A.R., China<\/option><option value=\"MK\">Macedonia<\/option><option value=\"MG\">Madagascar<\/option><option value=\"MW\">Malawi<\/option><option value=\"MY\">Malaysia<\/option><option value=\"MV\">Maldives<\/option><option value=\"ML\">Mali<\/option><option value=\"MT\">Malta<\/option><option value=\"MH\">Marshall Islands<\/option><option value=\"MQ\">Martinique<\/option><option value=\"MR\">Mauritania<\/option><option value=\"MU\">Mauritius<\/option><option value=\"YT\">Mayotte<\/option><option value=\"MX\">Mexico<\/option><option value=\"FM\">Micronesia<\/option><option value=\"MD\">Moldova<\/option><option value=\"MC\">Monaco<\/option><option value=\"MN\">Mongolia<\/option><option value=\"ME\">Montenegro<\/option><option value=\"MS\">Montserrat<\/option><option value=\"MA\">Morocco<\/option><option value=\"MZ\">Mozambique<\/option><option value=\"MM\">Myanmar<\/option><option value=\"NA\">Namibia<\/option><option value=\"NR\">Nauru<\/option><option value=\"NP\">Nepal<\/option><option value=\"NL\">Netherlands<\/option><option value=\"AN\">Netherlands Antilles<\/option><option value=\"NC\">New Caledonia<\/option><option value=\"NZ\">New Zealand<\/option><option value=\"NI\">Nicaragua<\/option><option value=\"NE\">Niger<\/option><option value=\"NG\">Nigeria<\/option><option value=\"NU\">Niue<\/option><option value=\"NF\">Norfolk Island<\/option><option value=\"KP\">North Korea<\/option><option value=\"NO\">Norway<\/option><option value=\"OM\">Oman<\/option><option value=\"PK\">Pakistan<\/option><option value=\"PS\">Palestinian Territory<\/option><option value=\"PA\">Panama<\/option><option value=\"PG\">Papua New Guinea<\/option><option value=\"PY\">Paraguay<\/option><option value=\"PE\">Peru<\/option><option value=\"PH\">Philippines<\/option><option value=\"PN\">Pitcairn<\/option><option value=\"PL\">Poland<\/option><option value=\"PT\">Portugal<\/option><option value=\"QA\">Qatar<\/option><option value=\"RE\">Reunion<\/option><option value=\"RO\">Romania<\/option><option value=\"RU\">Russia<\/option><option value=\"RW\">Rwanda<\/option><option value=\"BL\">Saint Barth&eacute;lemy<\/option><option value=\"SH\">Saint Helena<\/option><option value=\"KN\">Saint Kitts and Nevis<\/option><option value=\"LC\">Saint Lucia<\/option><option value=\"MF\">Saint Martin (French part)<\/option><option value=\"SX\">Saint Martin (Dutch part)<\/option><option value=\"PM\">Saint Pierre and Miquelon<\/option><option value=\"VC\">Saint Vincent and the Grenadines<\/option><option value=\"SM\">San Marino<\/option><option value=\"ST\">S&atilde;o Tom&eacute; and Pr&iacute;ncipe<\/option><option value=\"SA\">Saudi Arabia<\/option><option value=\"SN\">Senegal<\/option><option value=\"RS\">Serbia<\/option><option value=\"SC\">Seychelles<\/option><option value=\"SL\">Sierra Leone<\/option><option value=\"SG\">Singapore<\/option><option value=\"SK\">Slovakia<\/option><option value=\"SI\">Slovenia<\/option><option value=\"SB\">Solomon Islands<\/option><option value=\"SO\">Somalia<\/option><option value=\"ZA\">South Africa<\/option><option value=\"GS\">South Georgia\/Sandwich Islands<\/option><option value=\"KR\">South Korea<\/option><option value=\"SS\">South Sudan<\/option><option value=\"ES\">Spain<\/option><option value=\"LK\">Sri Lanka<\/option><option value=\"SD\">Sudan<\/option><option value=\"SR\">Suriname<\/option><option value=\"SJ\">Svalbard and Jan Mayen<\/option><option value=\"SZ\">Swaziland<\/option><option value=\"SE\">Sweden<\/option><option value=\"CH\">Switzerland<\/option><option value=\"SY\">Syria<\/option><option value=\"TW\">Taiwan<\/option><option value=\"TJ\">Tajikistan<\/option><option value=\"TZ\">Tanzania<\/option><option value=\"TH\">Thailand<\/option><option value=\"TL\">Timor-Leste<\/option><option value=\"TG\">Togo<\/option><option value=\"TK\">Tokelau<\/option><option value=\"TO\">Tonga<\/option><option value=\"TT\">Trinidad and Tobago<\/option><option value=\"TN\">Tunisia<\/option><option value=\"TR\">Turkey<\/option><option value=\"TM\">Turkmenistan<\/option><option value=\"TC\">Turks and Caicos Islands<\/option><option value=\"TV\">Tuvalu<\/option><option value=\"UG\">Uganda<\/option><option value=\"UA\">Ukraine<\/option><option value=\"AE\">United Arab Emirates<\/option><option value=\"UY\">Uruguay<\/option><option value=\"UZ\">Uzbekistan<\/option><option value=\"VU\">Vanuatu<\/option><option value=\"VA\">Vatican<\/option><option value=\"VE\">Venezuela<\/option><option value=\"VN\">Vietnam<\/option><option value=\"WF\">Wallis and Futuna<\/option><option value=\"EH\">Western Sahara<\/option><option value=\"WS\">Western Samoa<\/option><option value=\"YE\">Yemen<\/option><option value=\"ZM\">Zambia<\/option><option value=\"ZW\">Zimbabwe<\/option><\/select><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-2997-city\" class=\"vfb-address-label\">City<\/label><input id=\"vfb-field-2997-city\" class=\"vfb-form-control vfb-addresspart-city\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2997[city]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-2997-province\" class=\"vfb-address-label\">State<\/label><select id=\"vfb-field-2997-province\" class=\"vfb-form-control vfb-addresspart-province\" placeholder=\"\" required=\"required\" name=\"vfb-field-2997[province]\"><option value=\"\"><\/option><option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option><option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option><option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option><option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option><option value=\"DC\">District Of Columbia<\/option><option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option><option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option><option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option><option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option><option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option><option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option><option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option><option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option><option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option><option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option><option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option><option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option><option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option><option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option><option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option><option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option><option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option><option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option><option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option><option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option><option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option><option value=\"AA\">Armed Forces (AA)<\/option><option value=\"AE\">Armed Forces (AE)<\/option><option value=\"AP\">Armed Forces (AP)<\/option><option value=\"AS\">American Samoa<\/option><option value=\"GU\">Guam<\/option><option value=\"MP\">Northern Mariana Islands<\/option><option value=\"PR\">Puerto Rico<\/option><option value=\"UM\">US Minor Outlying Islands<\/option><option value=\"VI\">US Virgin Islands<\/option><\/select><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-2997-zip\" class=\"vfb-address-label\">Zip code<\/label><input id=\"vfb-field-2997-zip\" class=\"vfb-form-control vfb-addresspart-zip\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2997[zip]\"><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2998\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2998\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2998\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-2998\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2999\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2999\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2999\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-2998\" type=\"email\" name=\"vfb-field-2999\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField3000\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3000\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3000\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-3000\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Attendance Info <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3001\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3002\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3002\" class=\"vfb-control-label\">Section 3: Attendance Information<\/label><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3003\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3003\" class=\"vfb-control-label\">Which year(s) did you attend and\/or graduate from Breining Institute? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3003\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3003\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField3004\"><label for=\"vfb-field-3004\" class=\"vfb-control-label\">Breining Institute program(s) from which you graduated and\/or attended. Please select all that apply. <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" required=\"required\" type=\"checkbox\" name=\"vfb-field-3004[0]\" value=\"1\">FAST TRACK Program - 17 units<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" type=\"checkbox\" name=\"vfb-field-3004[1]\" value=\"1\">Addiction Studies Certificate (ASC) Program - 45 units<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" type=\"checkbox\" name=\"vfb-field-3004[2]\" value=\"1\">Associate of Arts in Addictive Disorders Degree Program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" type=\"checkbox\" name=\"vfb-field-3004[3]\" value=\"1\">Bachelor of Arts in Addictive Disorders Degree Program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" type=\"checkbox\" name=\"vfb-field-3004[4]\" value=\"1\">Master of Arts in Addictive Disorders Degree Program<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-3004-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-3004\" type=\"checkbox\" name=\"vfb-field-3004[5]\" value=\"1\">Doctor in Addictive Disorders (Dr.AD) Degree Program<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Where to send <span class=\"vfb-required-asterisk\">*<\/span><\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3005\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 4: Where do you want these transcripts sent?<\/div><span class=\"vfb-help-block\"><ul>\r\n \t<li>We will send one set of transcripts to the individual or institution you identify within this section.<\/li>\r\n \t<li>If a paper transcript is requested, we will send it by regular First Class mail using the U.S. Postal Service (USPS), to the mailing address you provide below.<\/li>\r\n \t<li>If an electronic PDF copy of transcripts is requested, it is only available to be sent directly to the student. If you, the student, would like to order an electronic PDF copy of your transcripts, you may select that option, below.<\/li>\r\n<\/ul><\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3006\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField3007\"><label for=\"vfb-field-3007\" class=\"vfb-control-label\">Please identify whether you are ordering a paper or an electronic PDF copy of your transcripts. <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3007-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3007\" value=\"I am ordering an electronic PDF copy of my transcripts to be emailed to me\">I am ordering an electronic PDF copy of my transcripts to be emailed to me<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3007-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3007\" value=\"I am ordering a paper copy of my transcripts to be mailed by USPS\">I am ordering a paper copy of my transcripts to be mailed by USPS<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField3024\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3024\" class=\"vfb-control-label\">Email address to send PDF transcript to Student<\/label><div><span class=\"vfb-help-block\">If the Student is ordering a personal copy of the PDF transcript, it will be emailed to the email address that you input below.<\/span><input id=\"vfb-field-3024\" class=\"vfb-form-control\" placeholder=\"\" type=\"email\" name=\"vfb-field-3024\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField3025\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3025\" class=\"vfb-control-label\">Confirm email address<\/label><div><input id=\"vfb-field-3025\" class=\"vfb-form-control\" placeholder=\"\" data-vfb-equalto=\"#vfb-field-3025\" type=\"email\" name=\"vfb-field-3025\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3027\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3027\" class=\"vfb-control-label\">If you are ordering a paper transcript, provide the mailing address below.<\/label><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3008\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3008\" class=\"vfb-control-label\">Name of the person<\/label><div><span class=\"vfb-help-block\">This is the person or institution that will be mailed the transcript. If it is you, please include your full name. If it is an institution, it is a good idea to have it addressed to an individual.<\/span><input id=\"vfb-field-3008\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3008\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3028\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3028\" class=\"vfb-control-label\">Name of the institution, if applicable<\/label><div><input id=\"vfb-field-3028\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3028\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3009\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3009\" class=\"vfb-control-label\">Address<\/label><div><input id=\"vfb-field-3009\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3009\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3010\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3010\" class=\"vfb-control-label\">City, State, ZIP Code<\/label><div><input id=\"vfb-field-3010\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3010\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Payment Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3011\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 5: Order<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3012\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField3013\"><label for=\"vfb-field-3013\" class=\"vfb-control-label\">You are ordering one set of transcripts. <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">PLEASE NOTE: If you need additional transcripts, you will need to submit a different order for each different address.<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-3013-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3013\" value=\"$75: I am ordering ONE (1) official, sealed transcript be sent via regular First Class USPS mail to the person and\/or institution identified in Section 4.\">$75: I am ordering ONE (1) official, sealed transcript be sent via regular First Class USPS mail to the person and\/or institution identified in Section 4.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3013-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3013\" value=\"$75: I am ordering ONE (1) electronic PDF copy of my transcripts be sent to me personally, to the email address provided in Section 4.\">$75: I am ordering ONE (1) electronic PDF copy of my transcripts be sent to me personally, to the email address provided in Section 4.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 6: Credit Card and Payment Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3015\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3016\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3016\" class=\"vfb-control-label\">You give permission to and authorize Breining Institute to charge the total amount of seventy-five dollars ($75.00) for the item selected in Section 5, above, to the following credit card:<\/label><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField3017\"><label for=\"vfb-field-3017\" class=\"vfb-control-label\">Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3017-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3017\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3017-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3017\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3017-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3017\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField3018\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3018\" class=\"vfb-control-label\">Credit Card Number: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3018\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"number\" name=\"vfb-field-3018\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3019\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3019\" class=\"vfb-control-label\">Full Name on Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3019\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3019\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3020\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3020\" class=\"vfb-control-label\">Credit Card Expiration Date <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3020\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3020\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-signature\" id=\"vfbField3021\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3021\" class=\"vfb-control-label\">Signature<\/label><div><span class=\"vfb-help-block\">Please carefully use this space to sign your name, which must match the signature we have on record in your student file.<\/span><input id=\"vfb-field-3021\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" type=\"hidden\" name=\"vfb-field-3021\" value=\"\"><div class=\"vfb-signature\"><\/div><div class=\"vfb-signature-buttons\"><a href=\"#\" class=\"btn btn-primary\">Reset Signature<\/a><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField3022\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3022\" class=\"vfb-control-label\">Captcha <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"g-recaptcha\" data-sitekey=\"6LdWgN0UAAAAAM_hb1SqmzT2DP4J1X289K2epOVA\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField3023\"><button id=\"vfb-field-3023\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/section><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":27,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-8665","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/8665","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/comments?post=8665"}],"version-history":[{"count":3,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/8665\/revisions"}],"predecessor-version":[{"id":23981,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/8665\/revisions\/23981"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/27"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=8665"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}