Student ID #:
(Full name as you want it to appear on your certificate)
I will complete requirements for the following Certificate(s) by the end of:
Summer__________ December____________ May _____________
(Year) (Year) (Year)
Current Degree (check one): MBA:_____ MSN:_____ Current Advisor:_____________________________
Students earning a degree will not earn a given Graduate Academic Certificate if more than 1/3 of the
coursework (not including pre-requisites) for said Graduate Academic Certificate satisfies the student’s
degree requirements.
Please circle the certificate you are achieving:
Example: Entrepreneurship
Entrepreneurship (BMEN-CERT-G)
Information Systems Data Management (ISDM-CERT-G)
Project Management (BUPM-CERT-G)
Please print permanent (home) mailing address below:
Street Apartment Number City State Zip
Country (if not U.S.)
Home Phone Work Phone Cell Phone
Student’s Signature Date
I have discussed the student’s plans to complete all certificate requirements and feel they should graduate by the date indicated above:
Advisor’s Signature Date
Please return the completed form to the Registrar’s Office-Room 16, Gorin Hall
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