Please print name as you would like it to appear on your certificate.
Student Name: ________________________________________ Student ID: ___________________________
Mailing Address: ___________________________________________________________________________
Phone: ______________________________________ Program: _____________________________________
The certificate request form MUST BE SIGNED BY YOUR ADVISOR and returned to the Registrar’s
A DegreeWorks audit must be provided with this request. If the DegreeWorks audit shows the student
has not completed certificate requirements, the form will not be accepted.
The student must be enrolled in the certificate program to be awarded a certificate.
Certificates are awarded in December, May and August.
Student Signature: __________________________________________ Date: ___________________
Advisor Signature: __________________________________________ Date: ____________________
6/2020 lml
Certificate Request Form
Office of the Registrar
379 Belmont Road, Laconia, NH 03246
Phone: (603) 524-3207 Fax: (603) 524-8084