Certification Intent Form

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FOR OFFICE USE ONLY
Campus/Location ________________________
Amount Received________Receipt No._______
Clerk’s Initials __________ Date ____________
CERTIFICATION INTENT
TROY UNIVERSITY
The following name should be engraved on my certificate: (Use complete name. Married women may use maiden name as
middle name.) PLEASE PRINT CLEARLY.
____________________________________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
Student ID Number:_____________________________________
Current Mailing Address:______________________________________
Phone(
)______________________________
______________________________________
E-mail Address____________________________
Work Phone(
) __________________________
Cell Phone (
) __________________________
Troy University—Troy
___Troy University—Dothan
CAMPUS/LOCATION:
___Troy University—Phenix City
___Troy University—Montgomery
___Troy University—Global Campus (location)________________________________
___Troy University—eTROY
I intend to complete my certificate at the end of (check one)
Fall____ Spring____ Summer____
with the following degree:
Or Term I____ II____III____IV____V____, 20___
___Addictions Counseling
___Post Masters Clinical Mental Health Counseling
___Biomedical Sciences
___Post Masters Family Nurse Practitioner
___Taxation
___Government Contracting
___Health Practice Management
This "CERTIFICATION INTENT" should be filed with the Campus Registrar according to the date published in the course schedule. The
non-refundable certification fee must be paid at the time the "INTENT" is filed. Students who fail to complete course work as scheduled must
refile their "CERTIFICATION INTENT." For this "CERTIFICATION INTENT" form to be valid, the form must be completed, signed, and
dated.
I hereby certify that the above information is accurate.
__________________________________________
Date
(Signature)
YOUR CERTIFICATE FEE MUST BE PAID AT THE TIME THIS INTENT IS FILED
Distribution:
Original: -Registrar
Yellow: -Alumni Office
Troy Publication 104-320
Revised September 2014

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Parent category: Letters
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