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# 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)

Name: ___ Hometown (Required) ___

Note: Print full name as it is to appear on diploma

Name on University records (If different than above):___

Current E-Mail: ___ Current Phone Number: ___

Address after graduation: ___

Street City State Zip

Advisor: ___ Catalog/Entry: ___ Catalog/Major: ___

Degree: ___ First Major: ___ First Minor: ___

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)

Prefix & No. Title Hrs. Prefix & No. Title Hrs. Prefix & No. Title Hrs.

 — _____ _____

___

___

___

___

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### 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)

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

IV. Signature (Sign and Date)

Student: ___

Advisor: ___

Dept. Chairperson: ___

College Dean: ___

Registrar Certification: _____

Date: _____



Date: ___

Date _____

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.