PRINT THIS FORM then FAX (716-829-2475) or Mail
MILLARD FILLMORE COLLEGE
Certificate of Completion Request Form
Please print your name exactly as you wish it to appear on the certificate.
NAME _________________________________________________________________________
Address _______________________________________________________________________
City ___________________________ State ____________________ Zip _______________
UB Person No _______________________ Email Address ________________________________
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(A) Circle the certificate that you are applying for:
Health Care Administration Computing & Network Management
Health and Human Services Microcomputer Business Applications
Paralegal Studies Network Management
Public Relations/Advertising Systems Analysis and Design
Entrepreneurship
(B) List courses taken and semester in which they were completed. You must have earned a minumim grade
"C" in each course listed below for Certificate requirements.
Course (Department and Course Number) Semester and Year Completed
NB: if the course is a substitution based on coursework completed at another college/university, please include the MFC Course Substitution Form along with this form. This form may be obtained by contacting the MFC office or downloading from this website.
Signature ______________________________ Date _________________________
MAIL THIS FORM TO:
University at Buffalo
Millard Fillmore College
3435 Main Street, 128 Parker Hall
Buffalo, New York 14214-8004
OFFICE USE ONLY: Checked:____________________________________________________
Certificate sent:_______________________
Revised 2/08 - DS
