Application for Certificate of Completion
1. Complete this form if you are completing the requirements for your Certificate program. Please print legibily.
2. This application will be effective for 3 consectative semesters, after that you will have to submit a new
Student Signature: You must sign this application or you will not be able to receive your certificate! If you have questions
about applying for certificate completion, please contact The Graduate School at (309) 677-2375.
Certificate Program (please check one)
Foster College of Business
College of Education and Health Sciences
Curriculum and Instruction
Counseling - Clinical Mental Health
Educational Administration (Type 75)
1501 W. Bradley Ave.
Peoria, IL 61625
I will complete my certificate requirements in:
How do you wish to receive your certificate? (please check one)
1. Mail to this name and address:
2. I wish to pick up my certificate at the Graduate School. (You will be contacted by email or phone.)
3. I wish to authorize another person to pick up my certificate at the Graduate School.
is authorized to pick up my certificate at the Graduate School.
Phone: (include area code)