GRADUATE CERTIFICATE COMPLETION FORM
Submit original to:
103 Fairchild Hall
List courses completed for certificate program
Total KSU Credits
Is this certificate to be prepared by the Graduate School?
Note: Credits that were earned more than six years prior to the semester in which the certificate is
approved cannot be accepted.
I hereby verify to the best of my knowledge that this student has or will have met the requirements of
completion for this certificate program by the end of this semester.
Signature of certificate program coordinator
Name of certificate program coordinator (Please Print)
Semester of completion:
Number Course Name
For GS Use Only:
______ C - DW