*****Must fill in all fields or the form will not submit*****
Graduating Year: 2024 2025 2026
Graduating Term: Summer Fall Spring
Please Select your Advisor: -------------------------------------------------------------------------------- Elizabeth Azhikannickal Stacie Campbell Jared Claytor Jamie Crawford Cathy Crum Christy Culver Rachel Darby Alexis Dowell Christine Drath Laura Emerick Trish Frazzini Stacie Groll Patty Hartman Natalie Hess Chad Hensel Cindy Hohman Feng Hua Lillie Kirsch Mandy Knight Josh Line Lori Makilagi Taylor Merritt Cal Morris Debra Myers Rodney Niese Maureen Pace Brandy Page Greg Perry Tara Rees Emily Rice David Richman Amanda Robinson Angie Romich Michael Shoemaker Joan Smalley Tim Stahle Caitlin Stansbery Kristy Taylor Elizabeth Teague Sandy Vent Mike White Carey Wolf ** MUST MAKE A SELECTION OR FORM WILL RETURN AN ERROR
Student Email Address:
Telephone Number:
Birth Date:
Name: (As you want it to appear on your certificate!)
First Name
Middle Name
Last Name
Street Address
City
State OH AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OK OR PW PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY
Zip code
County 01 ADAMS 02 ALLEN 03 ASHLAND 04 ASHTABULA 05 ATHENS 06 AUGLAIZE 07 BELMONT 08 BROWN 09 BUTLER 10 CARROLL 11 CHAMPAIGN 12 CLARK 13 CLERMONT 14 CLINTON 15 COLUMBIANA 16 COSHOCTON 17 CRAWFORD 18 CUYAHOGA 19 DARKE 20 DEFIANCE 21 DELAWARE 22 ERIE 23 FAIRFIELD 24 FAYETTE 25 FRANKLIN 26 FULTON 27 GALLIA 28 GEAUGA 29 GREENE 30 GUERNSEY 31 HAMILTON 32 HANCOCK 33 HARDIN 34 HARRISON 35 HENRY 36 HIGHLAND 37 HOCKING 38 HOLMES 39 HURON 40 JACKSON 41 JEFFERSON 42 KNOX 43 LAKE 44 LAWRENCE 45 LICKING 46 LOGAN 47 LORAIN 48 LUCAS 49 MADISON 50 MAHONING 51 MARION 52 MEDINA 53 MEIGS 54 MERCER 55 MIAMI 56 MONROE 57 MONTGOMERY 58 MORGAN 59 MORROW 60 MUSKINGUM 61 NOBLE 62 OTTAWA 63 PAULDING 64 PERRY 65 PICKAWAY 66 PIKE 67 PORTAGE 68 PREBLE 69 PUTNAM 70 RICHLAND 71 ROSS 72 SANDUSKY 73 SCIOTO 74 SENECA 75 SHELBY 76 STARK 77 SUMMIT 78 TRUMBULL 79 TUSCARAWAS 80 UNION 81 VAN WERT 82 VINTON 83 WARREN 84 WASHINGTON 85 WAYNE 86 WILLIAMS 87 WOOD 88 WYANDOT
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Please select the Department your major is in. EXAMPLE if graduating from nursing please select nursing as your department. -------------------- Diagnostic Medical Sonography Arts and Sciences Business Technologies Criminal Justice Engineering Technologies Social Work and Addictions Health Information Technologies Information Technologies Medical Laboratory Nursing OTA PTA RAD Respiratory Therapy Medical Assisting ** MUST MAKE A SELECTION OR FORM WILL RETURN AN ERROR
I AM PETITIONING TO RECEIVE THE FOLLOWING 1 YEAR TECHNICAL CERTIFICATE. (Please check the box next to your certificate program.)
I hereby petition to receive a certificate from Marion Technical College. I have completed all the above information, have met with my advisor and know I will meet all requirements for graduation at the end of the listed Term/Year above.
Any questions direct them to the Office of the Registrar email at the email address listed below.
Petitions must be completed by the dates listed above.
College Registrar, Marion Technical College 1467 Mount Vernon Avenue Marion, OH 43302-5694 Phone: 740.389.4636 Fax: 740.389.6136 registrar@mtc.edu