Florida International University
Office of the Registrar
Certificate Program Application

Instructions: Type or Print in ink.
° Complete the form, sign it, and turn it in to the academic department.
° Have all transcripts from your previous institutions mailed directly to the academic department.
° The academic department will notify you of their decision.
° If you are an international student, contact the Office of Admissions regarding your visa status.
° If you are applying also for a degree program, you must complete a separate admission application and turn it to the Office of Admissions.

Certificate Program: _________________________________________________  Code: (Office use) _____________

Social Security Number (SSN): |__|__|__|-|__|__|-|__|__|__|__|           Term: _____________________________

Name: (Print, one character per block. Leave one block between names)

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Last Name                                                                                                 First Name                                                                        M.I.

Permanent Address:

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Number and Street                                             City                                   County             State        Country                Zip Code

Local Address:

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Number and Street                                             City                                   County             State        Country                Zip Code

Telephone Number:  Area Code: __________           Number: ___________________________

Nation of Citizenship: _____________________  Place of Birth: ______________________  Birth Date: _______________
Sex:  Male ____     Female ____
Race:  ( Required by US Department of HEW under Title VI of the Civil Right Act)
(A) - Asian or Pacific Islander: ____                (B) - Black: (not of Hispanic origin) ____                (H) - Hispanic: ____
(I) - American Indian or Alaska Native: ____             (W) - White: (not of Hispanic origin) ____
Have you previously applied to a degree program at FIU:  Yes: ____       No: ____
Are you presently enrolled or plan to enroll at FIU:  Yes: ____      No: ____     If Yes, what College/School: ________________
Degree Program: __________________________
List in chronological order each college or university you have attended, or plan to attend before entering FIU's Certificate Program:
Name of School                                                               Location                           Dates of Attendance (From--To)        Degree Earned

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

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Test Scores:  GMAT: __________      GRE: __________      TOEFL: __________

Have you ever been found by any school authorities or by any court to have disrupted or interfered with the orderly conduct, processes, functions, or programs or any educational institution?     Yes: ____   No: ____

If 'Yes', please give details: __________________________________________________________________________________

_______________________________________________________________________________________________________

Are you currently charged or have you been convicted of found guilty (even if adjudication withheld) of violating any federal or state law or municipal ordinance other than minor offenses involving a fine of $500.00 or less?      Yes: ____  No: ____

If 'Yes', please give date, name of court, nature of offense, and penalty imposed, if any: ____________________________________

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