Fillable APPLICATION FOR ACADEMIC CERTIFICATE GENERAL INFORMATION (California State University, Sacramento)

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APPLICATION FOR ACADEMIC CERTIFICATE GENERAL INFORMATION (California State University, Sacramento)

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APPLICATION FOR ACADEMIC CERTIFICATE
GENERAL INFORMATION
Please read the information below before completing the
Application for Academic Certificate Application
Academic Certificate Fee(s) – Please pay the $10.00 fee at the Brusar’s Office (Lassen Hall)
before submitting the form to the Office of Graduate Studies (River Front Center, Room 215). Pl
ease
read the information below before completing the academic certificate application.
Due Dates: Return this form to the Office of Graduate Studies by the date noted below:
October 1 (for Fall Certificate Completion) / February 1 (for Spring/Summer Certificate Completion
Changes to Academic Certificate Application - Make a copy of this application for your records. If
y
ou have changes, please visit the Office of Graduate Studies, River Front Center, Room 215.
Approval of Academic Certificate Course Verification – If you do not have an approved
Academic Certificate of Completion Course Verification form on file with the Office of Graduate Studies,
your Application for Academic Certificate application will be returned to y
ou.
Certificate Mailing Address- You will receive your certificate approximately six (6) months after
Completion of Certificate Program.
Note: If your address is different than the one listed on this form, you must file a "Data Change Form"
with the
Office of Graduate Studies or update your records on your My Sac State account.
Approval Signature – Obtain the appropriate signature of your departmental faculty advisor.
D
ec 2017
Student ID #:
MI:
Other:
Date:
Approved:
FIRST Name
Certificate Mailing Address: Your certificate will be sent to the address below. If you move prior to
completing your certificate, please complete a "Data Change Form" and return it to the Office of Graduate
Studies (River Front Center - Room 206).
Please pay the $10.00 academic certificate fee at the
Bursar's Office in Lassen Hall.
Posted by:
Course Currency Exp.:
DUE: October 1 (Fall) / February 1 (Spring)
Acct Code: TS034 - 501870 - 63800-$10.00
Last Name:
LAST Name
Phone:
Email:
Name on Certificate (legal name used while attending the university):
Faculty Advisor
Date
Academic Certificate Application:
Address:
Signature of Graduate Coordinator or Department Chair (see back for more details)
Student Signature:
Certificate Conferral Date:
Checked By:
2017 May
Cashiers Receipt
Read each section carefully to avoid mistakes and delays
Office of Graduate Studies
Application for Academic Certificate
Date
Certification Date:
Middle
Office of Graduate Studies Use
Notes:
Spring
Summer
Fall
Year:
Enter appropriate authorized academic certificate program:
Name:
Ms.
Dr.
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APPLICATION FOR ACADEMIC CERTIFICATE GENERAL INFORMATION (California State University, Sacramento)

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Completed 18 August 2020

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