Name of Student:

Class Year:

College Box No:

Home address if applicable (i.e. letter to be sent here):

Number of copies:

Name and address of recipient, if different from above:

Special instructions (i.e. specific information to be included in addition to name, class year, dates of full-time attendance, degree pursued/date awarded):

SIGNATURE _____________________________________               Date _________________

If you are picking up the certification letter and wish to be notified when it is ready, put your email address here: