Sign this form and fax with credit card payment to (714)241-6365; - or - Mail with payment to

Military Contract Education - Coastline Community College, 11460 Warner Ave, Fountain Valley, CA 92708-2597

COASTLINE COMMUNITY COLLEGE • 11460 Warner Avenue, Fountain Valley, CA 92708-2597 • Ph: (714) 241-6168

1. NAME - PLEASE PRINT 2. OTHER NAMES USED 3. CCC OLD I.D. NUMBER
(Prior to 1989)
_______________________________________________________________________________________________________________________ ________________________
Last First Middle
________________________ _______________________

4. ADDRESS 5. BIRTHDATE 6. SOCIAL SECURITY #

____________________________________________
_______________________________________________________________________________________________________________________ Mo. Day Yr. ________________________
Number and Street Apt. No.
R EQUEST

_______________________________________________________________________________________________________________________
City State Zip Code 7. PHONE NO. 8. LAST YEAR ATTENDED
(Approximately)
( ________________________
) Semester ________ Year ____

9. STUDENT'S SIGNATURE 10. TODAY'S DATE 11. NUMBER OF COPIES

TRANSCRIPT

_______________________________________________________________________________________________________________________
Signature Authorizes Release of Records ________________________ ________________________

12. SEND TRANSCRIPTS: (The first two transcripts are free.) 14. GENERAL EDUCATION CERTIFICATION (Coastline
NOW (allow 10 working days) —$3 per copy Student copy—$3 per copy Community College will certify only once.) This service is only
used when you are ready to transfer to a participating four-year
WITH Final Grades, Semester _________________ $3 per copy university.
(accepted two weeks or less prior to the end of the semester)
CSU (General Education Certification)
RUSH (PICK-UP)—$5 additional charge per copy (pick-up after 24 hours) Note: *Pass along will be processed upon completion of 12 units at CCC.
OFFICIAL

Note: Copy will be destroyed after 60 working days. IGETC (Intersegmental General Education Transfer Core)
Note: CCC must be your last community college attended.
With General Education Certification or IGETC, (complete #14)
COMPLETE FOR IGETC OR CSU GEC

Pink • Student Copy

1. Is this your last community college attended? Yes ____ No __
13. HOLD FOR CHANGES: (Changes will delay mailing) 2. Are you using high school records to fulfill
Academic Renewal AA/Certificate Posting IGETC requirements? Yes* ___ No __
3. Have you attended other colleges/universities? Yes* ___ No __
Grade Change Repeat/Delete *If yes, list all other colleges/universities attended for pass along
certification (if applies):
Semester _________________________________ Year _____________________ ______________________________________________________
______________________________________________________
Course No. and Title ___________________________________________________

White • CCC
**Official transcript must be on file at Coastline Community College.

STUDENT IS RESPONSIBLE FOR COMPLETE MAILING ADDRESS. PLEASE PRINT

LEGIBLY FOR USE IN WINDOW ENVELOPE. DO NOT ABBREVIATE SCHOOL NAMES.
OFFICE USE ONLY
MAIL TO:

DATE: _______________________ BY: ________________________

ID: __________________________ PAID: _______________________

Yellow • Transcript
COMMENTS:

April/06 SS2: 4235.2

METHOD OF PAYMENT: Check Money Order Credit Card: VISA MasterCard Discover
Credit Card No. Exp.Date: Billing Zip
Authorizing Signature_____________________________________________________ Date_________________