Application for Degree/Certificate
Jefferson Community College/Enrollment Services
Mail or email completed form to:
1220 Coffeen Street
Watertown, NY 13601
Phone: 315-786-2437
Fax: 315-786-2349
Please Note
Enter your current address or the address to which your diploma should be mailed.
Name: (Please Print) ___________________________________
Student ID Number: ___________________________________
Mailing Address: (Please enter address and telephone)
Street: __________________________________________
City: __________________________________________
State/Zip: __________________________________________
Telephone: __________________________________________
I hereby certify that I expect to complete the requirements and graduate:
Degree Program: ____________________________________ Verified by _____________
(Office use only)
Date of Graduation: __________________________________ Verified by _____________
(Office use only)
Please Sign and Date:
Signature: __________________________________________
Date: _____________________________________________
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