Lower Columbia College Registrar • 360-442-2370 • http://lowercolumbia.edu/registration
11/17 RLP/KDM
Office Use:
QTR ________
Exit Code _______
PRG Code _______
Application for Certificate of
(Please check one)
Completion (-45 credits) Proficiency (45+ credits)
Instructions: This application is to be signed by the faculty advisor before submitting to the
Registration Office.
The Certificate will not be awarded until the end of the quarter in which it was received.
Candidate’s name as it should appear on the certificate:
First Name Middle Name or Initial Last Name
Student ID #: ________________________ Social Security # ____________________________
Title of the program for which the certificate is being issued:
The total number of credit hours earned to complete the certificate: ________
Date/QTR of Completion: __________________
Certificates will be mailed to address indicated below.
Student address: __________________________________________________
Email (print clearly) __________________________________________________
Phone (_________) _____________________________
Advisor’s Signature (required) _________________________________________________
Student Signature ______________________________________ Date ________________
_______ Cer
tificate Graduation List ______ Master Graduation List ______ Intent Code
_______ QT
R LAST2/SM5001 (Opt 3) ______ Coded on Transcript ______ Certificate Prepared
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