Office of Graduation Services, 4000 Lancaster Drive NE, Building 2, Room 200,Salem, OR
Mailing Address: PO Box 14007, Salem, OR 97309-7070
Phone: 503.399.6588 Fax:503.399.3918 Email: email@example.com
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To request this publication in an
ernative format, please call 503.399.5192.
2/1/2019 s:\registrar\forms\application for cert or degree.docx chemeketa.edu
Application for a Certificate or Degree
Use this form to apply for a Certificate or Degree and as a request to review your completed graduation requirements. We will notify
you that you have either completed the requirements for your degree or if there are outstanding requirements that still need to be met.
1. Complete and submit this form to Graduation Services by the end of the fourth week of the term prior to the term in which
you expect to complete graduation requirements.
a. You will receive an email to your MyChemeketa prior to registration of your final term if received by this deadline.
If submitted after the deadline, this may take up to 7-10 weeks to process.
b. In order for your name to appear in the commencement ceremony program, please visit the Commencement
Ceremony page for the due date. https://www.chemeketa.edu/students/student-services/graduation-
c. Only submit this application if you are within 2 terms of completing requirements for your program.
Student ID (K#): Date of Birth (mm/dd/yyyy):__________________
Name (as it appears in our records): __________________________________________________________________
Last First Middle
Diploma Name (PRINT EXACTLY as you want it to appear on your diploma.):
Street City State Zip
Phone Number with Area Code: Cell Phone: _______________________ Home Phone: ________________________
Select the term in which you will complete your program: Fall Winter Spring Summer Year ________
Indicate degree (Choose ONE. If completing more than one certificate/degree fill out a separate application):
Associate of Arts Oregon Transfer (2 year)
Associate of General Studies (2 year)
Associate of Science (
Associate of Science/Oregon Transfer in Business (2 year)
Associate of Science/Oregon Transfer in Computer Science (2 year)
Certificate of Completion in __________________________________
Associate of Applied Science in _______________________________
Catalog Year to be used for evaluation: _________ ‘catalog year’ is typically the year you began taking courses to meet your
(If your studies are interrupted by two years or more, or if your course of study extends beyond five years, graduation requirements may
changed and you may have to complete additional requirements.)
Do you have transfer credits to apply toward your certificate/degree that have not already been transferred in? Yes No
If yes, from where?_______________________________________________
Do you have any substitutions to apply towards this certificate/degree? Yes No
* Once certificate or degree information has been posted to your account, we are unable to remove it.
Student Signature: _________________________________________________________Date:___________________
click to sign
click to edit