Adult High School Diploma Application Form

Adult High School

DIPLOMA APPLICATION

A Diverse Learning Community | An Equal Access/Equal Opportunity College

Please print your legal name.

_____________________________________________________________

________________

NAME:

SSN#

First

Middle

Last

_________________

Student ID#

______________________________________

____________________________________

PHONE:

EMAIL:

ADDRESS FOR DIPLOMA MAILING:

__________________________________________________________________________________________

Street

Apartment #

__________________________________________________________________________________________

City

State

Zip Code

Applying for the following:

q Standard High School Diploma

q Certificate of Completion W8A “College Placement Test Eligible”

I plan to complete all graduation requirements and would like to receive my

diploma/certificate at the end of :

q Term IA, October graduation

q Term I, December graduation

q Term IIA, March graduation

q Term II, April, May graduation

q Term IIIA, June graduation

q Term III or IIIB, August graduation

I understand that my graduation is contingent upon my successful completion of all

diploma/certificate requirements and not having any restrictions on my record.

Student’s Signature ________________________________________________Date___________________

Counselor’s Signature ______________________________________________Date___________________

Seminole State Social Security Number Collection Statement

Seminole State College of Florida recognizes that an individual's Social Security number is a unique form of identification that can be utilized to obtain sensitive information regarding

that particular individual. However, the College must collect Social Security numbers in order to be able to properly perform its duties and functions as an educational institution and in

order to ensure that such duties and functions are performed accurately and efficiently.

The College is allowed to collect Social Security numbers in accordance with 119.071(5) (a), FS; and Section 1008.386, F.S.; IRC Section 25A and SBE Rule 6A-1.0955(3) (e) and FWS 34

CFR 668.36

Office Use Only:

Overall G.P.A. __________ Honors Status ____________ Certified By_______________ Date ___________

Original – Registration Office

Copy – Student

259485 rev 8-2012