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Replacement Certificate Request
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Requestor Name:
*
Your answer
How would you like to receive your certificate?
*
Mail (provide mailing address below)
Pick up at the Chemeketa Salem Campus
Email (for insurance purposes only)
Other:
Mailing address (if mail option was selected above)
Your answer
What is the primary need for the replacement certificate?
Choose
DMV waiver
Insurance
DMV waiver & Insurance
Other
What year did the student take the course?
Choose
2016
2017
2018
2019
2020
2021
What term did the student complete?
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Fall
Winter
Spring
Summer
Unsure
Location the course was taken at
*
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Chemeketa Salem Campus
Chemeketa Eola
Chemeketa Yamhill Valley Campus
Central High
Dallas High
Fall City High
Silverton High
South Salem High
Sprague High
Stayton High
Woodburn High
Unsure
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