Student Information

Name    

Address 

Phone    

Signature
                                                Must be signed by student

Please choose one of the following:

Hold for pickup    Please pickup the following business day

Fax                      Please provide fax number  

Mail                      Please provide address below

*If student does not designate where to send, it will default to the address above

Name    

Address 

Purpose of Certification:

Health Insurance      Car Insurance   Loan Deferment   Other

After completing the form please print and send to Gainesville State College.  The form may be fax, mailed or dropped off:

Gainesville State College
Oconee Campus
P. O. Box 1748
Watkinsville, GA 30677

Fax number: 706-310-6202

If you have questions or comments please call 706-310-6201