REQUEST TO GRADUATE Southeastern Community College
Degree/Diploma/Certificate Request Section (to be completed by student)
It is my belief that I will have completed the requirements for graduation from the program for which I am enrolled at the end
of: (please check one and fill in the year). Incomplete forms will be returned to you.
Fall Semester (Aug-Dec) Spring Semester (Jan-May) Summer Term Year ________
Which commencement ceremony do you plan to attend? Check one: W Burlington Keokuk Not Attending
This is to certify my intention to graduate. I will be receiving: (please check one)
**If you are completing more than one degree/diploma/certificate, please submit a separate form for each one.
Associate of Arts Associate of Applied Science
Associate of Science Program Name ____________________________________
Diploma Transfer Major __________________________
Program Name ____________________________________
Program Name ____________________________________
Are you a military veteran? Yes No
Are you a TRIO student? Yes No
I would like my name to appear on my degree/diploma/certificate exactly as follows:
PLEASE PRINT: _____________________________________________________________________________________
First Middle Name or Initial Last
Full Mailing Address where you want your degree/diploma/certificate mailed:
House Number and Street City State Zip Code
Preferred E-mail Address: ___________________________________________________________________________
(Provide the e-mail address you check the most often. You will receive all notifications regarding your request at this e-mail address)
Home Phone: Cell Phone: _____________________________________ _______________________________________
Student ID: ___Date: _Signature: ______________________________________ ________________ ______________
or DOB or last 4 digits of SSN
If you satisfactorily complete ALL of the classes in which you are enrolled as of this date, you will meet the requirements for the
degree/diploma/certificate specified above.
If you satisfactorily complete ALL of the classes in which you are enrolled as of this date, you will only have the remaining
requirements (indicated below) to complete by the end of the next session.
term. The reason(s) are indicated below: You are not eligible to graduate at the end of the _____________
Specific category not satisfied:
Insufficient number of semester hours Communications _____________________________
Number Short Humanities _____________________________ __________________
Insufficient Grade Point Average Social Science _____________________________
Current GPA Math/Science _____________________________ __________________
15 of the last 20 semester hours not earned Cultural Awareness _____________________________
through SCC Still need to complete ___________________________
Changed Major/Program____________________________________________
* If you are currently enrolled, or plan to enroll in the near future, to correct any deficiencies noted above, please notify the Registrar’s
Office to insure that your transcript can be re-evaluated at the end of that period.
** Please note that you are still eligible to participate in commencement exercises held in May if you are planning to complete your
degree/diploma/certificate by the end of the Summer session.
*** Participating in the commencement ceremony does not mean you have earned your degree/diploma/certificate, you MUST complete all
Date: Registrar’s Signature: _______________________________________________ _______________________
Date MailedDate Ordered REGISTRAR USE ONLY: Date Awarded ____________ ____________ ____________
Did NOT meet degree/diploma requirements PTK
Rev. 3/2020
Date Form Received _____________ Date Entered in SGRD _____________
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