LB REVISED 02/21/19
After completing and signing this form, submit to Office of Admissions & Records, Bldg. 700
or mail to: Chabot College
Admissions & Records
Enrollment Verification Processing
25555 Hesperian Boulevard
Hayward, California 94545
ENROLLMENT VERIFICATION REQUEST
Date of Request: ________ - __________ - ________
Number of copies requested: ______
W ID or SS Number: _____________________________
Are you currently enrolled?
Yes
No
(Please Print Clearly)
Name: _________________________________________________
Last First Middle
Street Address: __________________________________________
City, State, ZIP: __________________________________________
Telephone: _____________________________________________
Birthdate: ___ ___ / ___ ___ / ___ ___ ___ ___
Other name or alias: ______________________________________
TYPE OF INFORMATION TO BE VERIFIED: (check one)
If no box is checked, a verification of enrollment for the current term will be
processed.
Verification of enrollment for __________________
(Term/Year)
Verification of degree(s) earned at Chabot College
Letter of Non-Attendance
Complete the attached inquiry form (e.g. Loan Deferment forms,
Training Verification form for Child Care)
Special Instructions: _______________________________________
________________________________________________________
PLEASE CHECK ONE:
I will pick up verification at the Office of Admissions & Records. (Photo ID required at time of pick up)
Send verification to: (1 request form per address listed) ~ (Please print complete name of recipient & address legibly)
NAME or INSTITUTION
:
ATTENTION:
ADDRESS
Number, Street:
City, State & Zip:
Signature of student authorizing release of enrollment verification: _________________________________________________ Date: _________________
ENROLLMENT VERIFICATION POLICIES
1. Please allow three (3) business days for processing (with some exceptions).
2. Chabot College will forward record of work completed at Chabot College and Las Positas College only.
Information regarding course work completed at other institutions is NOT included.
3.
If sending verifications to different recipients, please use a separate form for each recipient
.
Please mail this completed form to:
Chabot College
Admissions & Records
Enrollment Verification Processing
25555 Hesperian Blvd.
Hayward, CA 94545
FOR OFFICE USE ONLY
Received By: _______________ Date Processed: ___ ___ / ___ ___ / ___ ___ ___ ___
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