After completing this form and obtaining the appropriate signatures, return it to the Records & Advisement Office
PERSONAL INFORMATION Please print clearly
Name_______________________________ I.D. #______________________
Local Phone # Cell Phone__________________
E-Mail Address____________________________________________________
Major(s) 1.__________________________2.____________________________
Minor(s) 1.__________________________2.____________________________
Degree(s) Catalog Year_________________
YOUR DIPLOMA NAME: Print your name exactly as you want it to appear on
your diploma. Use upper and lower case letters and accent marks (if applicable).
First Middle Last Suffix
Middle Last
I plan to graduate in: December May__________
I will be present at the graduation ceremony:* Yes No
*If you will be present at the ceremony, you must order regalia at
ACADEMIC INFORMATION For Student and Adviser
Student: By checking these boxes, I acknowledge that I am responsible for meeting ALL
graduation requirements as stated in the university catalog.
Adviser: By checking these boxes, I confirm that the student has completed the following
graduation requirements.
A minimum of 64 hours; Nursing majors need 69
hours and Physical Therapy majors need 92 hours
A cumulative & Southern GPA of 2.00; Refer to
school or department for major GPA
Completion of a major; general education and
electives to satisfy the total credit requirements.
One Service Level 1 and one Service Level 2 or 3
(not required for catalog years prior to 2011-2012)
SENIOR CLASS SCHEDULE Are you taking any classes off campus?* Yes No If yes, which semester(s)? Fall Winter Summer
Course # & Title Fall Sem./Year__________ Credits
Course # & Title Winter Sem./Year__________ Credits
Course # & Title Summer Session/Year__________ Credits
Total Hours_________
*Home Study/Off-Campus Course Title College/University
Total Hours_________
Total Hours_________
Total Hours_________
By signing this contract, all parties confirm the information is correct to the best of their knowledge. Any changes must be approved by the Adviser AND the Asst.
Director of Records & Advisement, and will require submission of a new contract.
Student:_____________________________ Date:________ Adviser:____________________________ Date:_________ Asst. Dir. of Records:________________________ Date:_________