*Student ID: *Email:
*First Name:
Middle Name:
*Last Name:
*Telephone:
*Address: Current on File: New/Updated (enter address below):
Street: City: State: Zip Code:
For New Certifications or Changes to an Existing Certification, Please Complete the Following:
1. Have you requested certification before? Yes No
Intersession/Spring Summer Fall Year:
2. What term are you requesting a new certification for?
3. Do you have a Student Educational Plan on file with the Counseling Office (You must have a Student Educational Plan on file prior to the end of your first semester of attendance)? Yes No
*What is the last month of the year? (this question helps protect AVC from spam)
*Required
A copy of this information will be e-mailed to you. If you want a hard-copy, please print this page for your records.
