CertificateofProficiencyApplicationForm.pdf Rev. 03/08/18
MIRACOSTA COLLEGE
APPLICATION
CERTIFICATE OF PROFICIENCY
Name
Print name exactly as it is to appear on certificate. (First, Middle, Last – use upper and lower case)
Student ID Number: Birth Date:
Telephone Number: E-mail:
Address to Mail Certificate:
Name of certificate for which you are applying (please use exact title):
(Certificate titles can be found in MCC catalog)
Number of units required for this certificate: units
Have you completed ALL course requirements for this certificate? Yes No In Progress
If No or In Progress, at the end of which semester do you anticipate completing your certificate program? Example: Fall 20 18
Fall 20 Spring 20 Summer 20
Do you have any Substitution/Waiver forms on file at MiraCosta identifying courses to be used for this certificate?
Yes No If yes, the Substitution/Waiver form(s) must be attached and turned in with this application
List any/all courses (from colleges other than MiraCosta) that you plan to apply toward this certificate:
Are transcripts for the above named course(s) on file at MiraCosta College? Yes No
Official transcripts must be on file at MiraCosta College or attached to this application.
*** READ CAREFULLY BEFORE SIGNING ***
Note: If you intend to include a Substitution/Waiver form and/or coursework completed at another institution, these documents must
either be on file at MiraCosta College or attached to this application. Certificates can only be awarded after certificate requirements
are verified by MiraCosta personnel.
Applications may be returned to Daria Davis in OC4818 on the Oceanside Campus; emailed to dariadavis@miracosta.edu,
OR they can be mailed to the following address:
MiraCosta College
Attn: Daria Davis
One Barnard Drive, M/S 21
Oceanside, CA 92056
Student Signature: Date:
FOR OFFICE USE ONLY
Certificate Courses Confirmed:
