Petition for Certificate of
Achievement
Name
Print name exactly as it is to appear on certificate. (First, Middle, Last – use upper and lower case)
Student ID#
Address
Number Street City Zip
Home
Phone
( ) -
Email:
Major:
The requirements for this certificate will be completed by:
Fall
□
20
Spring
□
20
Summer Session
□
20
List all courses in progress, including those at other colleges, which are required to complete this
certificate:
Course Units
Course Units
Course Units
Course Units
NOTE: If you have courses in progress at another college which are required to complete this
certificate, official transcripts must be submitted to the Admissions & Records Office at the end of
the term.
List all colleges from which you have coursework to be considered for this certificate:
READ CAREFULLY BEFORE SIGNING
In order to have this evaluation form processed for the current term; I understand that it is my
responsibility to see that all required official transcripts and substitution/waiver forms are on file in
the Admissions & Records Office by the petitioning deadline.
Comments:
I grant permission to MiraCosta College to include my name on the graduation program and any
graduation lists that may be released to the public.
Student Signature Date
Oceanside Campus: Submit completed form to Admissions & Records, MiraCosta College, One Barnard Drive, Oceanside, CA 92056 or fax to 760-795-6626.
San Elijo Campus: Submit completed form to Admissions & Records, MiraCosta College, 3333 Manchester Ave., Cardiff, CA 92007 or fax to 760- 634-7875.
