________________________________________ ___________________________
Insured’s Name:____________________________
Type of degree
Insured’s ID #: ____________________________
Program (major/curriculum)
Anticipated graduation date ____________________
Current schedule of classes
Request certification sent to:
(Please include the complete name, telephone number, and email address.)
Signature of Student Request Taken by
Note: If you are sending this request from an email address other than your SCCC email, you must include a copy of your
Driver License for the purpose of authentication and signature comparison.
For Office Use Only: (CERTREQ)
Processed by: __________________________ Campus:_______________ Date:__________________
Revised: 4/21/2020
Enrollment status for the _______________________ term (semester)
Start and end dates
Suffolk County Community College
Registrar Office
Enrollment Certification Request Form
Please show the information you would like to have included in your certification letter. If you are requesting specific
academic and/or course information, you should send a transcript request form instead so that we may send your official
transcript. Please note: Enrollment certifications sent only after the start of classes. However, you may receive a
pre-certification letter when you make payment of your schedule. This form will only certify that you are
registered; not enrolled. Please contact your insurance company regarding their policy on pre-certification
letters. Please allow 7-10 business days for processing.
Name __________________________________________ Student ID # ____________________
Telephone Number _______________________________ Date __________________________
The following information should be included in the certification letter (check all that apply):
Ammerman: registrara@sunysuffolk.edu
Eastern: registrare@sunysuffolk.edu
Michael J. Grant: registrarw@sunysuffolk.edu
Please complete this form and email it to your campus
registrar at one of the following email addresses:
For Insurance Requests Only: