• • • • •
GUILFORD TECHNICAL COMMUNITY COLLEGE
PO Box 309 • Jamestown, NC 27282 • 336-334-4822 or 336-454-1126 • TTY 336-841-2158
Application for Certificate
Please print and complete entire form
Legal name only — no nicknames, etc. — (Must match school records)
Maiden Name (if applicable)
Address: ______________________________________________ City: __________________________State:_________
Zip: ________ Email: ________________________ Date of Birth: ____________ Student ID: ______________________
Telephone Number: Home: __________________ Business:__________________ Cell: ____________________
If you would like to have your Permanent Record updated to include the name and address on this application, please
submit a “Change of Address/Telephone Number Form” to the Student Success Center at any of the GTCC campuses.
Please Check One of the Following
Award Semester/Year Completed Duplicate/Copies
I am applying for: Certificate FA _____ SP ____ SU _____ Certificate Duplicate
(Advisor signature required)
(If graduated, advisor signature not required)
I am obtaining my certificate in (Program Name): ____________________________________________________________
(Program Code): ____________________________________________________________
IMPORTANT - READ BEFORE SIGNING
I hereby apply for the Certificate Program listed above. I understand that I must complete an audit with my Department
Chair or *Advisor unless already graduated. I must pay a non-refundable Certificate Fee at the Cashier’s Office and return
the receipt along with the Certificate Application to the Records Office on the Jamestown Campus or to the Student Success
Center on the Greensboro, High Point, Aviation, or Cameron Campus. The Certificate Fee is $5.00.
The Certificate Fee is Not Refundable. Instructions for E-Degree students link
Applicant's Signature: *Advisor's Signature:
Date: Advisor Name (Print) Ext.
Certificate Payment Received (Cashier’s Office)
Records Processing Center
SGRD Entry: _____________________
Appl. Entry: ______________________
GPA: ___________________________
Grad: __________________________
DOD Entry: ______________________
Print Date: ______________________
IASU Paid: ______________________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
