APPLICATION FOR CERTIFICATE OF ACHIEVEMENT

You should apply for the certificate after the beginning of the semester in which you expect to complete your certificate requirements. For Columbia College students only: To guarantee that your name is printed in the commencement program at Columbia College, your application must be received by April 1st.
__________________________ Social Security Number or Student ID	____________ Birth Date	___________________ Semester of Completion

I WISH MY NAME TO APPEAR ON MY CERTIFICATE AS FOLLOWS:

_______________________________________________________________________________________________________
Last Name	First	Middle	Previous Name

I wish to apply for a certificate for _______________________________________________________

Title of Certificate as it appears in the Catalog

Catalog Year I am following ______________

My mailing address is: _________________________________________________________________________________________

Street Address

City

State

Zip Code

My permanent address is: ______________________________________________________________________________________

Street Address

City

State

Zip Code

E-mail Address: ___________________________________________

My phone number is: _______________________

I authorize Yosemite Community College District to print my name in the commencement program and to release my name to local newspapers.

Yes

_______________________________________________	____________
Signature	Date

	Print and fill out this form. Sign and fax, or mail it to MJC or CC:
	Modesto Junior College, Evaluations Office 435 College Avenue Modesto, CA 95350 209-575-6695 - FAX	Columbia College, Admissions & Records 11600 Columbia College Drive Sonora, CA 95370 209-588-5337 - FAX