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: ____________________
Office of the Registrar
379 Belmont Road, Laconia, NH 03246
Phone: (603) 524-3207 Fax: (603) 524-8084