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