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High School Completion
STUDENT INFORMATION
section
Last Name
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First
*
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Middle
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Birthdate
field type date
Student ID #
*
field type single line
Must be 7 digits. Example 0123456.
Input blocked. Maximum character limit of 4000 characters reached.
Other names used
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email Address
*
field type single line
example@mycod.us
Input blocked. Maximum character limit of 4000 characters reached.
Daytime Phone Number
field type single line
Input blocked. Maximum character limit of 4000 characters reached.
HIGH SCHOOL INFORMATION (Choose one)
section
field type radio button
I received a High School diploma from:
I received my G.E.D from:
I passed the California High School Proficiency Exam at
field type single line
Name of School
Input blocked. Maximum character limit of 4000 characters reached.
field type single line
City
Input blocked. Maximum character limit of 4000 characters reached.
field type single line
State OR Foreign Country
Input blocked. Maximum character limit of 4000 characters reached.
I started attending this high school in
field type single line
Month/Year
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and graduated in
field type single line
Month/Year
Input blocked. Maximum character limit of 4000 characters reached.
field type single line
Name of School
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on
field type single line
Month/Year
Input blocked. Maximum character limit of 4000 characters reached.
field type single line
City
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field type single line
State OR Foreign Country
Input blocked. Maximum character limit of 4000 characters reached.
field type single line
Name of School
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on
field type single line
Month/Year
Input blocked. Maximum character limit of 4000 characters reached.
STUDENT NOTIFICATION
section
Allow 10 business days for processing.
I certify the information provided is correct.
Please Print your Full Name
*
field type single line
This constitutes as your e-signature
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Date
*
field type date
Spam capture please leave empty