Reference Columbia State Policy 02:02:00
Revised 6/18
_________________________________________________________________________________________________________________
REQUEST FOR TECHNICAL CERTIFICATE
1. Eligibility and Instructions for completing this form:
• Students who are seeking an AA, AFA, AS, AST, or AAS degree must complete the Intent to Graduate form.
• Complete EVERY ITEM or your graduation evaluation will be delayed and the form returned for completion.
• DO NOT complete a Change of Major form – the major you list on this form becomes your new major.
2. PRINT
YOUR NAME AS YOU WANT IT TO APPEAR ON YOUR DIPLOMA
(This is also how your name will appear in the program and will be announced at the graduation ceremony.)
____________________________ ____________________________ _____________________________
Last Name First Name Middle or Maiden Name (optional)
3. Stud
ent ID Number: _________________________________________
4. I wi
ll take my final courses for my certificate the semester of: Fall 20____ Spring 20____ Summer 20____
5. I intend to complete the following certificate(s) with Columbia State by the end of the semester indicated above.
(Place a check mark by any that apply.)
_____ Ad
vanced Emergency Medical Technician
_____ Business
_____ Commercial Entertainment
_____ Computed Tomography
_____ Computer Networking
_____ Emergency Medical Technician
_____ Engineering Systems Technology
_____ Film Crew Technology
_____ Fire Science
_____ Hospitality and Tourism Management
_____ Paramedic
_____ Web Design and Mobile Technologies
6. Have
you previously been awarded a college certificate? __ No __Yes, what certificate? ____________________
7. Spr
ing completers who wish to participate in the May ceremonies must submit this form by the last Friday of
February. Summer or Fall completers who wish to participate in the December ceremony must submit this form
by the last Friday of September. To participate in the graduation ceremony, specify below.
_____ Yes, specify Height ____ Weight ____ (necessary to order academic robe)
_____ I am unable to participate in the ceremony.
8. Signatures are required: To ensure that you have completed the required number of credit hours and are indicating the
correct certificate on the Request, a signature from a college official is required. Officials can include advisors, deans,
academic division office staff, completion specialists, or extended campus staff. The Official will forward the Intent to
the Records Office or email to records@columbiastate.edu. from their Columbia State email.
Stud
ent’s Signature: ________________________________________________ Date: _____________________
Off
icial’s Signature: _________________________________________________ Date: _____________________
9. Once t
he Records office completes processing, you will receive an email via your Columbia State email that will
include information about your Request and other requirements.
Columbia State, a Tennessee Board of Regents institution, is an AA/EOE educational institution
