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certification-form - Page 1 of 1 ▪ Revised 05/2006 Return...

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Unformatted text preview: Page 1 of 1 ▪ Revised 05/2006 Return form in person to Student Services, 1207 LSA Building, 500 S. State Street or Room B-430 Pierpont Commons. Mail or fax form to the address/fax number listed above. PART I -- TO BE COMPLETED BY THE STUDENT – PLEASE PRINT OR TYPE U-M ID NUMBER OR SOCIAL SECURITY NUMBER ACCOUNT NUMBER (IF APPLICABLE) LAST NAME FIRST MIDDLE FORMER NAME, IF APPLICABLE STREET ADDRESS CITY STATE ZIPCODE PHONE NUMBER PLEASE NOTE BELOW ONLY THE INFORMATION THAT YOU NEED TO HAVE VERIFIED. THE UNIVERISTY OF MICHIGAN CAN ONLY CERTIFY TERMS FOR WHICH YOU HAVE REGISTERED. Enrollment (month/year ) : to Anticipated date of graduation (month/year): Degree(s) and Major/Field: Pre-registration (Indicate if certification is needed once you have registered but classes have not yet begun): Fall Winter Spring-Half Spring-Summer Summer-Half Degree(s) awarded (month/year): Degree(s) and Major/Field: Other: I AUTHORIZE THE UNIVERSITY OF MICHIGAN TO VERIFY AND RELEASE THIS INFORMATION TO THE NAME AND ADDRESS BELOW:...
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