APPLICATION FOR CERTIFICATE PROGRAMS

Instructions: Application fee is $25.00 by check or money order. Please complete all required information in the box below. Please remember to include your signature. Submit all copies of this form and the application fee to the Office of Records, Registration and Evaluations located in University Hall - 171; or you may mail it to the address listed above. NOTE: This office does not accept cash. Please see the Bursar's Office for cash payments. Questions regarding certificate programs should be directed to 909-537-5219.

Please tell us the name of the certificate program you are completing below: Certificate Program in_______________________________________________________________ Below, Please tell us the quarter and year in which you will be completing the certificate program: ___Fall ___Winter ___Spring ___Summer Year_____________ Print your name EXACTLY as you want it to appear on your certificate Name_____________________________________________________________________________ Mailing Address____________________________________________________________________ City______________________________________ State____________ Zip____________ Student ID No__________ Phone #___________ EMAIL Address_____________________________ Student Signature______________________________________ Today's Date____________ NOTE: It is the responsibility of the student to refile an additional application fee in the event of a change of name, term or requirements are not completed by the term for which you have filed. Student's initials____________

***FOR OFFICE USE ONLY*** ___Approved:   Certificate/Code_______________________________ Term Awarded____________ ___Denied:   Reason(s)_________________________________________________________________ Signature of School Official_________________________________________Date_________________ ************************************************************************************* Receipt Number___________________Fee______________Date________________Initials_____________

Distribution: White - Office Copy

Yellow - Institutional Research

Pink - College of Certificate Program