Receiver: ___________
White – Records Yellow – Student Form F rev 03/16 (web)
HONOLULU COMMUNITY COLLEGE
STUDENT REQUEST FOR VERIFICATION LETTER
OR CONSENT TO DISCLOSE EDUCATIONAL RECORDS TO THIRD PARTY
Name: _______________________________________________________Student ID/UH Username: _________________________
Print Last Name, First Name, Middle Initial
Address: _____________________________________________________________Telephone: _____________________________
Street, City, State, Zip Code
Email: _____________________________________________________________
I request the following: (Check all that apply)
Certification that I am currently enrolled for: Fall _________________ Spring _________________Summer ________________
Year Year Year
(Will be processed after the semester begins within 7 working days)
(If addressed to someone other than you, it will contain all periods of enrollment and degree information.)
(Home Institution must be Honolulu Community College and tuition must be paid in full.)
Certification that I have Pre-Registered for: Fall _________________ Spring _________________Summer ________________
Year Year Year
(Home Institution must be Honolulu Community College.)
Certification of my anticipated graduation date including major and degree type.
Visual inspection of my HonCC Records (Picture ID required). (No charge)
MyCAA Scholarship Education and Training Plan
Letter verifying completion of the Articulation agreement between HonCC Administration Justice Program and UH West Oahu
Justice Administration Program (Will be processed once program is completed and verified by program Counselor).
Other (must specify)_______________________________________________________________________________________
Please have my record(s): (Check one)
1. I will pick up my request. Photo I.D. is required. (You have 30 days to pick-up your request or it will be purged)
2. Mail to: (Please attach a self-addressed/stamped envelope)
3. Made available to __________________________________________________________________________________
Print Last First M.I.
(I authorize the person stated above to pick-up my records with his / her Photo I.D.)
I UNDERSTAND THAT THIS REQUEST WILL BE PROCESSED WITHIN 7 WORKING DAYS
Student’s Signature______________________________________________________________ Date _______________________
