Office of Workforce Development & Continuing Education
Application for Program Certificate

Semester ___________ Year _________
Name ____________________________________ Student ID # ___________
(Last) (First) (M.I.)
Name _________________________ ___________________ __________________
(Last) (First) (Middle Name/Initial)
(this is how your name will appear on your certificate)
Current Mailing Address: ___________________________________________________
___________________________________________________
Telephone Number(s): Home: (______) _________________
Work: (______) _________________
Name of Certificate Program:

___________________________________________________
Anticipated Date of Completion:

___________________________________________________
Certificates will be issued at the successful completion of all required course work. (Successful completion is defined as receiving a final grade of "P.") Certificates will be available in the Office of Workforce Development & Continuing Education approximately two weeks after completing your program requirements and the filing of this completed application. If you are moving out of the area before your certificate is available, please provide a forwarding address in the space below.
Forwarding Address: _________________________________________________________

Student's Responsibilities

  1. You must have completed all the program requirements prior to being awarded the certificate.

  2. The Office of Workforce Development & Continuing Education should have your current address and telephone number.

  3. You must return all materials belonging to the College or to the instructor(s).

  4. If you are eligible for a waiver or substitution of any course, written documentation from the instructor and Program Manager must be filed in the Office of Workforce Development & Continuing Education.

  5. You should consult with the Program Manager to ensure that program requirements have been met.

_____________________ __________________________________________
Date Student's Signature

Program Manager's Recommendation

As the Program Manager for this certificate program, I have reviewed this student's course records.

_____ I recommend this student be awarded the above referenced certificate.

_____ I do not recommend this student. He/She has the remaining requirements:

  1. ______________________________
  2. ______________________________
  3. ______________________________
_____________________ __________________________________________
Date Program Manager's Signature