Fill - Free fillable Verificationform (Cerritos College) PDF form

CERRITOSCOLLEGE

FOROFFICEUSEONLY

$2.00X__________Copies=__________

Rush‐24Hours

$7.00X__________Copies=_________

Date:____________Initials____________

Iherebyauthorizetheoﬃcials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

Address:_____________________________________________________________________________________________

No.andStreetName CityStateZipCode

Phone:______________________________StudentNo._______________________

Informationtobeveriﬁed(CheckallthatApply)

Veriﬁcation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:_____________________________

VeriﬁcationForm

***************************************************************STAFFUSEONLY**********************************************************

Mailedout_____/_______/________StaﬀInitials:_______________



Importantreminder:Priortoprocessingveriﬁcations,pleaseclearanyholdsorpayanyoutstandingfees.

DOB:__________________

_____VeriﬁcationofMajorofStudy



_____Veriﬁcationofdegreeissued _____Other:SeestatementBelow

_____UnitsCompleted

_____EnrollmentStatus(Full‐time,Part–Time)

_____CumulativeGradePointAverage

Otherinformationtobeveriﬁed:___________________________________________________________________________

_______________________________________________________________________________________________________

Note:AdmissionsandRecordsdoesnothavethecapabilitytoverifythefollowing:

>Calworks/Gainprograms‐PleaseseeCareerServices

>GPAforCalGrantAorBConsortiumAgreements–PleaseseetheﬁnancialAidOﬃce

Updated 5/13/2011 DB

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