December 2011
Petition for Certificate of Proficiency
Use this form to petition for a Certificate of Proficiency from Eastern Arizona College. If you have questions, please call EAC’s Counseling
Office at (928) 428-8253, or (800) 678-3808, Ext. 8253. Please print legibly.
EAC Campus/Extension where you are currently enrolled:
Thatcher
Graham Extension
Gila County
Greenlee Extension
Name: (As you wish it to appear on certificate)
First Middle Last
Mailing Address: (Where you would like the certificate mailed)
P.O. Box or Street, Apt. # City State Zip
Email Address: (Email address to contact for job placement)
Student ID Number: Date of Birth: Local Telephone Number: Year of EAC Catalog to be used:
Have you taken courses at another college or university which will apply to your certificate? Yes
No
If yes, please give name of college or university:
The requirements for the certificate were met Fall Spring Summer I Summer II semester of _______________________________ .
(academic year)
Certificate of Proficiency Title ____________________________________________ Certificate Program # _________________________
As required, I have attached a CARS Certificate Completion Report which I obtained from the Records and Registration Department or the
Counseling Department.
__________________________________________ _________________
Student Signature Date
Note: Submit the CARS Certificate Completion Report and this form to your Adviser or the Counseling Office. A notation is added to your transcript
by EAC’s Records and Registration Office upon completion of all certificate requirements. There is no fee to request a certificate.
For Adviser/Counselor Use:
Your academic records have been reviewed and indicate that:
You are eligible for the above listed certificate. Please allow 4 6 weeks for processing.
You have not demonstrated writing and/or math competency on an EAC approved writing and/or math test. Please make arrangements with the
Evaluation Unit, (928) 428-8491, to take the test.
You are not eligible this semester because: ________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
________________________________________________ _____________________
Adviser/Counselor Date
If the student is eligible for the above listed certificate, please submit this form along with a completed Certificate Request Form to Occupational
Dean’s Office. Otherwise, return to the student.
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