7351 Tompkins Hill Road
Eureka, CA 95501-9300
10. Print your name as you want it to appear on your certificate:
This name will be printed in the commencement program. Approved documentation required if deviates from name on file at CR.
Student Signature Date
FIRST, we want to know about your CR experience!
Complete this quick survey. https://www.surveymonkey.com/s/S2KSDG5
Campus Location: Eureka Del Norte Klamath-Trinity Mendocino
1. Name
Other names used while attending CR
2. Student ID#
3. Student Email Address
4. Permanent or forwarding address
for mailing certificate
5. Telephone Number
6. Anticipated Completion Date: Fall 20___ Spring 20___ Summer 20___
7. Certificate (choose one) Achievement Recognition
8. Title of Certificate:
Don’t forget to turn in your Certificate Petition by these dates:
Fall Semester Last Thursday in October
Spring Semester First Thursday in March
Summer Session Last Thursday in June
* Your certificate will not be mailed to you if you have a balance due to CR. Please contact the Business
Office at 707.476.4120 and pay any monies due to ensure you receive your certificate.
Evaluator Use Only
Catalog Year:
Yes No
Cumulative 2.0 GPA for
Certificate units?
Yes No
Number of units required:
Evaluator Signature Date
(Verification) Initials Date
Office Use Only
A & R Rec’d:_____________
Initials: _________________
(Checked for Counselor/Advisor sig)
click to sign
click to edit