Office Use Only:

Approved: YES NO

Office of Academic Affairs Representative, Printed Office of Academic Affairs, Signature Date

Plan Code: Cert. Plan Code:

Graduate Certificate for Degree-Seeking Students

Current degree-seeking students may use this form to elect a graduate certificate.

Instructions for this form: 1. Complete student information

2. Complete certificate election information

3. Obtain approvals prior to submission (electronic signature accepted)

Name: Student ID: Campus:

Program: Department: Major:

Elected Certificate:

If electing the Global Health Certificate, please state your interest(s) in electing this certificate:

Student, Printed Student, Signature Date

Faculty Advisor, Printed Faculty Advisor, Signature Date

Certificate Faculty Advisor, Printed Certificate Faculty Advisor, Signature Date (Required for Global Health, Maternal & Child Health, and Physical Activity & Health Certificates)

(Required for Global Health, Maternal & Child Health, and Physical Activity & Health Certificates)

Submit documents with signatures to: Office of Academic Affairs and Student Services (SPHAcademicAdvising@uth.tmc.edu)