CINEMA-TV DEPARTMENT
TELEVISION PRODUCTION CERTIFICATE REQUEST
If you have completed the courses below with a “C” or better you are eligible for the Television
Production Certificate.
Fill out this form and leave with the Department Chairman within the last three weeks of the semester.
Upon confirmation of your successful completion of classes, a certificate will be prepared for you.
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 Television 9
 Television 46
 Television 48 or 49
 Television 55 (or Cinema 33)
 Additional TV/Cinema class)
 Additional TV/Cin or Coop Ed class
Cinema 1
Cinema 2
Television 1
Television 4
Television 6 or 7
Or other Cin/TV Class _______
PERSONAL INFORMATION:
Date___________________ Birthday (month & day only) ________________
NAME________________________________________________________________________
(Please print name as it is to appear on the Certificate)
ADDRESS_____________________________________________________________________
CITY_______________________________________ STATE___________ ZIP____________
TELEPHONE____________________________ ______________________________________
(DAY)
(EVENING)
EMAIL_______________________________________
STUDENT ID NUMBER ______________ ---___________---________________
 I will pick-up Certificate
 Please mail certificate to above address
TO BE FILLED OUT BY OFFICE ONLY
DATE SUBMITTED:________________________________________________________________
DATE CONFIRMED:________________________________________________________________
DATE PRINTED: ___________________________________________________________________
DATE GIVEN TO VICE-PRES:________________________________________________________
DATE RETURNED TO CHAIR: _______________________________________________________
DATE CERTIFICATE GIVEN TO STUDENT_____________________________________________
 Picked Up
 Left on Door
 Mailed
May 16, 2012