MILLARD FILLMORE COLLEGE

Certificate Program Course Substitution Form

NAME _______________________________________________

ADDRESS  __________________________________________________

                   __________________________________________________

UB PERSON NO. _______________  UB EMAIL ADDRESS ___________@BUFFALO.EDU

PHONE __(    ) _______________      TODAY'S DATE: __________________________

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Certificate Program _________________  Course to be substituted ________________________

Substitution based on coursework completed at UB:

Course                                 Year                   Credit Hours                 Grade

________________          _______                 ________                     ____

Substitution based on coursework completed at other college/university:

Course                                 Year                   Credit Hours                 Grade____Institution

________________          _______                 ________                     ____     _____________

Policy on course substitution: Only one course may be substituted per Certificate application. A complete course description and unofficial transcript should be attached for any course completed at another institution. MFC Administration will determine the appropriateness of the substitution in the indicated certificate program.

MAIL THIS FORM ALONG WITH YOUR COMPLETED CERTIFICATE APPLICATION FORM TO:

                                            University at Buffalo

                                                      Millard Fillmore College

                                            Mr. David Stark

                                            3435 Main Street, 128 Parker Hall

                                            Buffalo, New York  14214-8004

FOR OFFICE USE ONLY   Approved   Denied  Signature ________________________________

Revised 2/08   - DS