Document Pick Up Authorization
Submit completed form to the Enrollment Services Oce with the authorized
persons picture ID in person, by email to MJCESeForms@mjc.edu, fax or mail.
If you would like to authorize another person to pick up your Award(s), Ocial Transcript(s) or Enrollment
Verication(s) please complete and sign the information below. Awards and/or transcripts will not be released without
this form and picture ID.
Date:
I authorize the following individual to pick up my: Award(s) Ocial Transcript(s) Enrollment Verication
from the Modesto Junior College Enrollment Services Oce.
Student Information:
First Name: Middle Initial: Last Name:
Student ID: w Birthdate: Phone:
I, understand that by signing this document I am giving permission to the authorized person to pick up the above
selected document(s) on my behalf. In the event damages should occur due to the release of such information, I
agree to hold Modesto Junior College harmless.
Student Signature: Date:
Authorized Person (please print full name):
To be signed by authorized person at time of pick up.
I, understand that by signing this document,I assume all responsibility for the handling of the above listed
students document(s).
Authorized Persons Signature: Date:
Oce Use Only
Received by: Date: ID Veried:
MJC Enrollment Services Oce • Phone (209)575-6853
EAST 435 College Ave. Student Services Bldg. 1st Floor • WEST 2201 Blue Gum Avenue, 1st Floor
10/2019_ SJB
click to sign
signature
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