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
Yes
No
Yes
No
  • IV. Signature (Sign and Date)

Student: ___

Student
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.