LONG ISLAND UNIVERSITY- BROOKLYN CAMPUS- OFFICE OF THE REGISTRAR
APPLICATION FOR DEGREE

FILL IN EXPECTED DATE OF GRADUATION: SEPTEMBER 200______JANUARY 200______MAY 200_________

HAVE YOU PREVIOUSLY APPLIED FOR THIS DEGREE? NO ________ YES ________ IF YES, INDICATE DATE______________

PRINT YOUR NAME AS YOU WISH IT TO APPEAR ON YOUR DIPLOMA:(YOUR NAME MUST CORRESPOND WITH YOUR NAME ON OUR RECORDS)

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FIRST NAME MIDDLE NAMELAST NAME

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NUMBER AND STREET CITYSTATEZIP CODE

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STUDENT ID NUMBER HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER

CHECK DEGREE EXPECTED:

AA _____ AAS ____ BA _____ BFA _____ BS _____ BS/MS _____

MA _____ MS _____ MFA _____ MS IN ED _____ MBA _____ MPA _____ MS/MBA _____

PH. D _____ D.P.T _____ PHAR. D _____spaceADVANCED CERTIFICATE _____ space CERTIFICATE _____


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MAJOR FIELD OF STUDY AREA OF CONCENTRATION

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SIGNATURE DATE

DIPLOMAS WILL BE MAILED APPROXIMATELY SIX WEEKS AFTER THE GRADUATION DATE.
INDICATE BELOW ANY ADDRESS OTHER THAN THAT ABOVE TO WHICH YOUR DIPLOMA SHOULD BE MAILED:


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NUMBER AND STREETSPACECITYSPACESTATESPACEZIP CODE

IF YOU PREFER TO PICK UP YOUR DIPLOMA, PLEASE CHECK HERE _________