Danville Area Community College Certificate Evaluation Form

Certificate Evaluation

Please print your name as you want it to appear on your certificate.

Name: _____________________________________________________________________ Date: ______________
Last First Middle Name/Initial

Social Security Number: ________________________________

Mailing Address:

Street and/or P.O. Box ____________________________________________________________________________

City ____________________________________ State _________________________ Zip Code ________________

Phone Number:

Area Code (_______) Number _______________________________

Candidate for a Certificate in _____________________________________________________________________

Indicate the year your certificate will be completed: _______________

Indicate the month your certificate will be completed: December January May August

For DACC Office Use Only

Counselor: ___________________________________________ Date: _____________________________

Approved: ____________ Denied: ____________

Academic Dean: ______________________________________ Date: _____________________________

Approved: ____________ Denied: ____________

Registrar: ___________________________________________ Date: _____________________________

Approved: ____________ Denied: ____________

Comments: ___________________________________________________________________________________

____________________________________________________________________________________________

G.P.A.: ____________ H.S. Diploma/GED: ____________

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