Certificate Request Form
Please fill out this form ONLY if you have completed all the requirements for either a Basic or Advanced Certificate found here: https://diversity.umn.edu/certificate

Basic Certificate:

Ten Certificate Program Workshops
(30 hours total)


Advanced Certificate:

Ten Certificate Program Workshops (30 hours total)

Application Component (6 hours)

Equity and Diversity Dialogue Circle (18 hours)
(54 hours total)


Direct questions about this form to John A. Williams, jawillms@umn.edu, 612-624-0594.
Certificate you have most recently completed *
BASIC = completed all 10 workshops | ADVANCED = completed all 10 workshops, application component, and Dialogue Circles.
First Name *
Last Name *
Name to appear on certificate *
Be sure to spell check! We will just copy/paste.
College/Unit/Department *
Position *
Choose one
Position Description *
If faculty/staff, please list your college/department/unit/program. If student, please list your college/major.
Employee or student ID number *
7 digits
Email *
Phone *
Mailing/Street Address *
For CAMPUS MAIL: Please include department, Room # & Building or MMC #, & Campus Delivery Code
City, State, Zip Code *
I give OED permission to share my name publicly (websites, email announcements, events, etc) as someone who has completed the OED Certificate Program *
I give OED permission to share my name with my Department Head and/or supervisor as someone who has completed the OED Certificate Program *
Comments:
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