Contact Information — Note: This is the address where all degree and/or certificate information will be mailed. You must notify our
office if you wish to change the address in the future.
Address: __________________________________________________________ City/State/Zip: ______________________________________
Phone:__(__________)_____________________________ E-mail Address: ________________________________________________________
Program/Catalog Information — Check the term and write the year in which you will complete your degree or certificate:
__________ Fall Semester
__________ Spring Semester
__________ Summer Semester
/ Year: ________________________
• Academic program code (degree/major field of study). Select from the choices given on the back of this form and then write the proper
program code here:____________________.
• Catalog used. Please write the catalog by which you wish to be evaluated (i.e., 2011-2012 catalog): ___________________.
College/University and Program Change Information
• Colleges attended. List all colleges and universities other than Lincoln Land Community College that you have attended if you wish to
apply that external coursework toward your degree or certificate program.
______________________________________________________________________________________________________________________
• Approved Program Change Petitions. (Does not apply to AA or AS degrees.) List all of the approved Program Change Petitions that you have
on file with the Office of Admissions and Records (students with approved PCPs have already been notified in the form of a letter).
Required course(s)
Substituted course(s)
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
I understand that withholding information requested on this application or giving false information may make me ineligible for
graduation. I certify that the above statements are correct and complete.
Signature: ____________________________________________________________________ Date: __________________________________
As a student at LLCC, I was aware of the college’s Behavior Intervention Team (BIT).
Yes
No
As a student at LLCC, I was aware of the Student Government Association (SGA), the official governing body for students.
Yes
No
As a student at LLCC, I was aware of the Learning Lab and the free services it offers.
Yes (go to question a)
No
a. I used the Learning Lab services while a student at LLCC.
Yes
No (go to question b)
b. I did not use the services because (check all that apply):
I did not think I needed any academic assistance such as tutoring, study skills, etc.
Service schedules of availability did not coordinate with my schedule.
I did not have any available time.
I was uncomfortable asking for assistance.
I did not know how to access the free services.
Other:____________________________________________________________________________