VERIFICATION REQUEST FORM
Admissions & Records Office, 3000 Mission College Blvd., Santa Clara, CA 95054-1897
Name: Phone:
Last First Middle
College ID#: E-mail:
Signature: Date:
Request verification for: Semester(s): Year:
Verifications can either be picked up or mailed: (please check one)
Mail to:
Pick-up:
rev. 09/28/11
Instructions: Please complete the following verification request form completely. Please
allow two (2) business days to complete your request.
Special Instructions
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Fax: ______________________
For Office Use Only:
Date Received:____________ Initial:_______
Complete Date: ___________ Initial:_______
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