Peru State College
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Certificates of Achievement Application

 

Legal Name
First Name, Middle Name: ,
Last Name:
Social Security Number: i.e. 555-55-5555
Gender: female male
Birth Information
Birth Month, Day, Year: , ,
Current/Mailing Address
Address:
City:
State, Zip: ,
Phone Number: i.e. 555-555-5555
Email Address:
Background Information
In compliance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments of 1972, this information is for reporting purposes only.
(optional) Ethnic Background:
When do you want to start classes?
Enrollment Semester:
Program Information
Heard about Program:
Desired Program(s):
Accounting
Classroom Behavior & Management
Criminal Justice
Human Resources Management
Human Services
Instructional Technology
Office Management
Retail Management
Writing For Publication
Course Number:
Course Name:
Program Objectives
What are you goals for earning a Certificate of Achievement? (Limit 2000 Characters)
 
Certification
When you submit this form, Peru State College will enroll you in the College and in the indicated course. If any change is needed to the information shown above, please contact a certificate specialist at (888) 258-5558 or (402)872-2219.

This application is valid for students desiring to take courses as part of a sequence leading to a Certificate of Achievement. These courses may be applied to full degree programs. A complete application is required for acceptance to a degree program. Further information is available from the Peru State College Admissions Office (402) 872-2221.