Name Student ID
(Please print your legal name. This is how it will appear on the degree, diploma, and/or cercate)
Address
(Street/Post Oce Box) (City, St, Postal Code)
Do you plan to parcipate in the graduaon ceremony held in May? Yes No
If Yes, complete the following: Height Weight
_______ Inial to deny permission for your name; degree program; and GPA (only if receiving an award) to be printed in the
commencement program, newspaper, and/or announced.
• Applicaon submission does not guarantee all graduaon requirements have been met.
Student’s Signature Date
$30 - First degree, diploma, and/or cercate
Amount Paid $
Date Paid
$5 - Addional diploma jacket for second
degree, diploma, and/or cercate
Receipt No#:
$5 - Addional tassel
$8 - US Postal Mailing Fee (per cover)
Total Amount Paid
PERC GPA
CRI Honors
IASU Privacy
EVAL Completed
Revised: 02/20
Received by Cashier:
First Degree - A.A.S. Diploma Cercate A.A. A.G.E.
Name of Program Program Code
Second Degree - A.A.S. Diploma Cercate A.A. A.G.E.
Name of Program Program Code
Third Degree - A.A.S. Diploma Cercate A.A. A.G.E.
Name of Program Program Code
Graduaon Term Spring Summer Fall Year
Advisor’s Signature
Date
Fourth Degree - A.A.S. Diploma Cercate A.A. A.G.E.
Name of Program Program Code
Please aach a current Evaluaon for each degree, diploma and/or cercate requested.
Telephone ( ) -
Alternate ( ) -
Check if you are currently in high school.
Yes No
Graduate’s Responsibility: One week before the Graduaon Commencement: Tickets, Caps & Gowns need to be picked up.
I will pick up please mail without cover please mail with cover $8 each
If Not parcipang in
commencement
