Student Name: ______________________________________________ Date of Birth: ________________________
Email Address: ___________________________________________________________________________________
Choose the one that best applies to you:
I certify that I have successfully graduated from high school with a standard diploma.
__________________ ____________________________________ _______________________
Date: Month and Year Name of School City and State
I certify that I have successfully completed a homeschool program.
Date: Month and Year_________________________
I certify that I have successfully completed a GED/HiSet.
Date: Month and Year_________________________
I certify that I have not yet graduated and received a high school diploma, federal aid eligible homeschool
credential or GED/HiSET, but will complete the requirement on:
Date: Month and Year_________________________
My signature below certifies that I have graduated or will graduate from high school or have received the equivalent of a
high school diploma (e.g., accredited alternative diploma program, HiSET or GED) by the start date of the semester for
which I am applying. I understand that if I provide false information about graduation from high school or equivalent, I
may be required to return any Title IV financial aid funds I receive. Falsification of records could also result in
disciplinary action from the College, including expulsion.
Transcripts may be used in course placement, and specific academic programs may require submission of high school
transcripts, including for proof of successful completion of specific courses; therefore, students are strongly encouraged
to submit transcripts in order to be accurately placed into college courses.
Signature: ________________________________________________ Date: _____________________
Terms of Use (electronic signatures): The Community College System of New Hampshire (CCSNH) uses electronic
signatures and records in place of traditional ones whenever possible. You will conduct business electronically with
CCSNH using a computer with a supported operating system and internet browser, sufficient electronic storage
capacity, a printer and your official CCSNH email account. By logging into CCSNH systems, including but not limited
to Banner SIS and Canvas, you are opting to conduct electronic transactions with the Community College System and
consenting to receive written notices electronically, including those involving financial obligations, and you are
acknowledging that CCSNH can use electronic mechanisms alone to convey critical information related to your
admission, financial aid, payment plan, student account, transcript information, registration and other activities and
accounts you may undertake or have as a student at CCSNH. You have a right to request a paper copy of an
electronic record. You may withdraw your consent at any time by contacting Student Services. If you decide to
withdraw your consent, however, you may be prevented from registering for classes.
04/10/2020
High School/Equivalent Completion
Self-Certification Form
Office of the Admission
379 Belmont Road, Laconia, NH 03246
Phone: (603) 524-3207 Fax: (603) 524-8084
Email: lrccinfo@ccsnh.edu
click to sign
signature
click to edit
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