APPLICATION FOR A CERTIFICATE

The University of Iowa

Submit to the Division of Interdisciplinary Programs Office
210 Jefferson Building
Iowa City, IA 52242

PLEASE PRINT OR TYPE

1. ___________________________________________

Type or Print Student ID Number

2. ________________________________________________________________________________
Last Name
First Name
Middle or Maiden

NOTE: Entering a name above that is different from the one on University records does not officially change your name. If the name above is not identical to the one on your records and you wish it to be used on your certificate, you must request and file a name change from Graduation Analysis, 1 Jessup Hall.

3. What Program Certificate are you applying for? _____________________________________________

3a. How did you find out about this Certificate/Program? ________________________________________

4. When do you expect to complete the requirements for your certificate? ________________
  Month         Year

5. Are you planning to apply for a minor in Aging Studies or AINSP? ____ Aging Studies ____ AINSP

6. Are you in a degree program? ______ Yes ______ No

6a. If yes, which degree are you pursuing? ___________________________________________

6b. When do you expect to receive your degree? ________________
  Month         Year
7. How do you expect to use this credential? What are some possible career options you are considering?

 

_____________________________________________________________________________

8. Forwarding address: ___________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

8. Email address: ________________________________________________________________

The University of Iowa requests this information for the purpose of processing your application for a certificate. No persons outside of the University are routinely provided this information, except for items of directory information such as name and local address. It is important that you keep us informed of address changes so that we can mail your certificate to you as soon as it is processed.

Requirement Complete_________________ Advisor ___________________ Date ________________