APPLICATION FOR UNDERGRADUATE DEGREE CHECKOUT FORM KENTUCKY STATE UNIVERSITY - OFFICE OF THE REGISTRAR (Revised 2022)
The student must apply for graduation the semester prior to the date of graduation. The deadline for submittal is found in the Academic Calendar.
The student must complete section I of this form, sign Section IV, and submit this application to the division chairperson or dean.
Approval must be obtained for minors/second majors from the appropriate divisional chairperson (and sign in Section IV).
The department must attach a copy of the curriculum checklist with notations of completed, substituted and waived courses.
I. Student Information
SID: ___ Expected Grad Date: ___ (Ex: Spring 2022)
SID
Expected Grad Date
Name: ___ Hometown (Required) ___
Name
Hometown (Required
Note: Print full name as it is to appear on diploma
Name on University records (If different than above):___
Name on University records (If different than above
Current E-Mail: ___ Current Phone Number: ___
Current E-Mail
Current Phone Number
Address after graduation: ___
Address after graduation
Street City State Zip
Advisor: ___ Catalog/Entry: ___ Catalog/Major: ___
Advisor
Catalog/Entry
Catalog/Major
Degree: ___ First Major: ___ First Minor: ___
Degree
First Major
First Minor
Second Major: ___ Second Minor: ___ Specialization: ___
Second Major
Second Minor
Specialization
II. Courses in Progress (For transfer courses, identify institution after course number)
Fall ___ (If applicable) Spring ___ (If applicable) Summer ___ (If applicable)
Fall
Spring
Summer
Prefix & No. Title Hrs. Prefix & No. Title Hrs. Prefix & No. Title Hrs.
— _____ _____
Prefix & No. Title [1]
Prefix & No. Title [1]
Prefix & No. Title [1]
___
Prefix & No. Title [2]
Prefix & No. Title [3]
Prefix & No. Title [4]
___ ___ ___ ___
Prefix & No. Title [2]
Prefix & No. Title [3]
Prefix & No. Title [4]
Prefix & No. Title [5]
Prefix & No. Title [5]
Prefix & No. Title [6]
Prefix & No. Title [6]
___
Prefix & No. Title [2]
Prefix & No. Title [3]
Prefix & No. Title [4]
III. Requirements (with above courses, will the applicant complete the following requirements?)
Are Liberal Studies Requirements completed (check applicable core)? ☐ Yes ☐ No General Core (42 hours) Whitney Young Core (48 hours)
No
Yes
Will courses in progress meet the minimum graduation hours required for the degree (120 hours)? ☐Yes ☐No Will courses in progress meet the minimum requirement for 300/400 level hours (42 hours)? ☐Yes ☐No
Yes
No
Yes
No
IV. Signature (Sign and Date)
Student: ___
Student
Date:
Date
Advisor: ___ Date: ___
Date
Advisor
Dept. Chairperson: _____ Date _____
Date
Dept. Chairperson
College Dean: ___ Date: ___
Date
College Dean
Registrar Certification: _____ Date: _____
Registrar Certification
Date: ___
Date
It is the Policy of Kentucky State University not to discriminate against any individual in any of its educational programs, activities, or employment on the basis of race, color, national origin, sex, disability, veteran status, age, religion, or marital status.