3000 Campus Hill Drive, Livermore CA 94551 Admissions & Records Office Fax (925) 606-6437
Year: 20 _
FALL Anticipated Completion: SPRING SUMMER
SSN/“W” User ID:W
*Name: _
First
Middle/Maiden
Last
*
Address:
Street City
State Zip
Phone
:
Email:
Home Work
*
Your name and permanent address as currently listed in the College’s student information system will be used to print on your diploma. Any
changes to either your name or address must be made by completing a Student Data Change Form available at Admissions & Records Office
or
website.
Date Stamped Received
Indicate which of the following you are petitioning for. Please refer on the College catalog or counselor for degree and
certificate majors.
Catalog Year:
(If item is left blank or not appropriate, current catalog will be used.)
Check only one degree:
MAJOR CODE:
MAJOR TITLE:
Please read and check before signing below:
Submitted official copies of transcripts (high school and college) from ALL other previously attended accredited post-secondary
institutions.
Advance Placement (AP)/International Baccalaureate (IB) Exam and/or Course Substitutions/Waivers form are on-file if applicable.
Veterans Only: DD-214 on file and verified by VA Coordinator/Designee.
If I do not complete my requirements in the current academic semester, I must re-apply. I understand the reponse time is 8-12 weeks.
Student Signature: Date
By signing above, I certify that my application is complete and accurate. I am responsible for knowing the information provided.
SUBMIT THIS FORM: Attn: Request for Degree/Cert Las Positas College 3000 Campus Hill Drive, Livermore, CA 94551 or 925.606.6437 (fax)
or lpc-admissions@laspositascollege.edu, Subject: Request for Degree/Cert
REQUEST FOR DEGREE OR CERTIFICATE
Associate in Arts
Associate in Arts for Transfer
Associate in Science
Associate in Science for Transfer
Certificate of Achievement
OFFICE USE ONLY: _____SHADEGR _____ BDMS _____DD-214 VERIFIED
RESULT: _____ COMPLETED _____ DENIED
NOTES:___________________________________________________________
__________________________________________________________________
EVALUATOR: ______________________ DATE: ________
Request for Degree cert 2017-2018
19.SEP.2017 JS