2700 East Leland Rd.
Pittsburg, CA 94565
Phone (925)439-2181 ext. 7500
Verification of Enrollment Form Revised 12/06/13
Verification of Enrollment
Enrollment Verifications ordered directly through the Admissions and Records office are
processed as follows: The first two verifications are free.
Today’s Date: Student ID#:
Print Name:
Last First M
Other Last Name(s) used: Date of Birth:
Email Address @insite.4cd.edu Phone:
LMC Email Address Telephone Number
Number of Copies
Standard $2 Mailed within 3-5 business days
Rush $5 Mailed after 1 business day.
Rush $5 Pick-Up after 1 business day (pick up requests are in person only)
Send Enrollment Verification to:
Office/Attn:
Address:
City/State/Zip:
Student Signature:
Office Use Only
Received by: Date: Paid:__________
Sent by: Date:
