Undergraduate Certificate Application
for the Plan of Study
Certificate Start Date: ________________________________________________________________________
Name: ______________________________________ E-mail Address: ____________________________
Clemson ID:
qqqqqqqqq
Local Mailing Address: (Street/P. O. Box) ________________________________________________________________________
___________________________________________________________________________________________________________
(City)
(State)
(Zip)
Add:
Certificate Name:_____________________________________________________________________
Certificate Program Code:______________________________________________________________
________________________________________________ Student’s Signature
________________________________
Date
________________________________________________ Certificate Program Director (Print Name)
________________________________
Date
________________________________________________ Certificate Program Director (Signature)
________________________________
Date
Please print address for Plan of Study form to be mailed to Certificate Program Director:___________________
________________________________________________________________________________________
Office Use Only
Recorded by Enrolled Student Services:______________________________ ______________________
Date
Return completed form to 104 Sikes Hall
Rev. 06/2015
Certificate Program Procedures
1. The student and Certificate Program Director will complete an Undergraduate Certificate application available
at: http://www.registrar.clemson.edu/pdf/planOfStudy.pdf.
The Certificate Application will include:
• Student Name
• Clemson ID Number
• Mailing address and E-mail address
• Certificate Program Start Date, Program Code and Program Name
• Student signature
• Certificate Program Director signature
2. Completed form must be returned to Student Records, 104 Sikes Hall.
3. Upon receipt, the Undergraduate Certificate Plan of Study form will be forwarded to the address of the Certificate
Program Director indicated on the front page of this form.
Office of Records & Registration
104D Sikes Hall, Clemson University
Box 345125
Clemson, SC 29634-5125
Fax 864.656.0622