Please review back for graduation
requirements and procedures
Application for Certificate from Mt. San Jacinto College
PLEASE PRINT MY NAME ON THE CERTIFICATE AS FOLLOWS:
Name _________________________________________________________________________________________________________
PRINT: First Middle Last
Former Name ____________________________________ I.D. Number _____________________ Birthdate _______________________
Address _________________________________________________________________________ Phone _________________________
Street
_______________________________________________________________________________
CITY STATE ZIP
Program Completion for the end of: ____Summer _____Fall ____Spring 20______Year
Where should certificate be mailed if not to the above address?
Address: __________________________________________________________________________________________________________________
STREET CITY STATE ZIP
Other Colleges Attended: ___________________________________________________________________________________________
Personal Email: ___________________________________________________________________________________________________
Certificate Program Applying for: ___________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
This is not an Employment Concentration Certificate. See an Evaluator for questions.
I understand that if I do not want my name published in the commencement program handed out at graduation, I must file a Student Petition
Form with the Evaluation office before May 1
st
; otherwise my name WILL be printed.
All existing programs of study not listed on this application will be closed and those listed will be added if necessary. Programs with lacking
graduation requirements will also be closed when deemed ineligible.
Signature ____________________________________________________________________________ Date _______________________
*If you update your address online via EagleAdvisor, you will need to contact the Evaluator’s office to update your diploma address if necessary.
OFFICE USE ONLY
Math competency: Yes No N/A
Comments: Please refer to the academic evaluation enclosed
Reading competency: Yes No N/A
12 unit residency
requirement met: Yes No
GPA requirement:
(Minimum 2.00 GPA) DA:
Requirements Completed
and/or In Progress: Yes No
9/6/18 ES 457 White – Student file Yellow – Student Copy
Do you plan on participating in
the commencement ceremony
at the end of Spring?
Yes □ No □
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signature
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