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Date
Name and Address of Supplemental Institution
This is to certify that (Student's name), (Claim Number) whose major is (Name of Program), may enroll in the following courses at (Name of Supplemental Institution) during the (Show the term, fall, spring, etc.), 20__.
List of course(s) by title and number:
Student (IS/IS NOT) concurrently certified at this school in (Number of Hours) for the period (Beginning through ending date of period enrolled).
The number of hours of previous training that apply are (Insert prior credit).
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