CINEMA-TV SKILL CERTIFICATE REQUEST
If you have completed the courses listed below with a "C" or better you are eligible for a Skills Award.
Fill out this form and leave with the Department Chair CC#181. Upon confirmation of your successful
completion of classes, a certificate will be prepared for you. Please indicate whether you will pick up (we
have awards ceremonies) or would like it mailed. Certificates are typically mailed in January and July.
☐ Television Studio Production Skills Certificate (Level I) (12 units)
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Television 1
Television 4
Television 9
Television 46
☐ Beginning Cinema and Television Skills Certificate (12 units)
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Cinema 1
Cinema 2
Television 4
Television 9
☐ Cinematography Skills Certificate (12 units + Cinema 1,2,3,4)
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Cinema 6
Cinema 7
Photography 7
Photography 10
☐ Directing Skills Certificate (15 units + Cinema 1,2,3,4)
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Cinema 5 or Television 25
Cinema 10
Cinema 20
Theater Arts 200
Theater Arts 225 or Theater Arts 300 (substitute)
☐ Producing Skills Certificate (15 units + Cinema 1,2,3,4)
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Cinema 5 or Television 25 (Screenwriting)
Cinema 20
Cinema 25
Business 1
Law 33 (Media Law)
PERSONAL INFORMATION: Please CHECK the certificate(s) you are requesting.
Today’s Date__________________ Birthday_______________ (month & day only)
NAME__________________________________________________________________________
(PLEASE PRINT NAME AS IT IS TO APPEAR ON THE CERTIFICATE - CAPS OR LOWER CASE)
ADDRESS_______________________________________________________________________
CITY/STATE/ZIP/COUNTRY ______________________________________________________
TELEPHONE: _________________________________________________________
EMAIL _____________________________ Student ID Number __________--- _________---________
☐ I will pick up
☐ Please mail to address above
TO BE FILLED OUT BY OFFICE ONLY :
DATE CONFIRMED: _____________________________________________________
DATE PRINTED: ________________________________________________________
DATE GIVEN/RETURNED TO CHAIR/VICE-PRESIDENT_________________________________
DATE CERT. GIVEN TO STUDENT OR MAILED________________________________________
(skills form 12/14/2014)