$2.00 X __________ Copies = __________
Rush- 24 Hours
$ 7.00 X __________ Copies= _________
Date: ____________ Initials ____________
I hereby authorize the ocials of Cerritos College to transmit information regarding my academic progress and other
data requested by the agency, company, or person indicated below.
STUDENT’S SIGNATURE: _______________________________________ Date: _________________
Indicate Semester: _____Fall _____Spring _____ Summer Year: ____________
Name: _______________________________________________
Please print clearly
No. and Street Name City State Zip Code
Phone : ______________________________ Student No. _______________________
Information to be veried ( Check all that Apply)
Verication will be: (Check one )
Rush (Allow 24hrs for processing) Pick up Mail to student Mail to Third party
Regular Service (Allow 10 working days for processing) Mail to Student Mail to Third Party
Mailing Information:
Third Party Name:______________________________________________________ Dept: ______________________
Attention : ______________________________________________
Address: ___________________________________________________________________________________________
Number and Street City State zip code
Date: _____________________________
Verication Form
*************************************************************** STAFF USE ONLY **********************************************************
Mailed out _____ /_______ /________ Sta Initials: _______________
Important reminder: Prior to processing verications, please clear any holds or pay any outstanding fees.
DOB: __________________
_____ Verication of Major of Study
_____ Verication of degree issued
_____ Units Completed
_____ Loan Deferment
_____ Enrollment Status ( Full-time, Part–Time)
_____ Cumulative Grade Point Average
Other information to be veried: ___________________________________________________________________________
Note: Admissions and Records does not have the capability to verify the following:
> Cal works /Gain programs-Please see Career Services
> Ocial document will be destroyed at the end of the term if not picked up.
> GPA for Cal Grant A or B Consortium Agreements– Please see the nancial Aid Oce
We cannot release your records to a third party without expressed written consent. If you want a third party to pick up your Verication, please submit a consent form.
The consent form may be found on our webpage at the following link: http://cms.cerritos.edu/uploads/AdmissionsandRecords/pdf/Consent_Form.pdf
Updated 3/31/2015