*Legal Name:

*Student ID number:

*Email Address:

*Telephone Number:

*Receiving Institution:

*Mailing Address 1:

Mailing Address 2:

City*

State*

Zip Code*

Certification Code:

• GE= California State University General Education Breadth Certification
• IGETC= Intersegmental General Education Transfer Curriculum

*Type of Certification:
Type of Certification GE IGETC