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)

PLEASE PROVIDE A COMPLETE CAMPUS MAIL ADDRESS WHEN POSSIBLE.

Direct questions about this form to Ralph Blanco, rblanco@umn.edu, 612-625-8680.

Certificate you have most recently completed *
BASIC = completed all 10 workshops | ADVANCED = completed all 10 workshops, application component, and Dialogue Circles.
First Name *
Your answer
Last Name *
Your answer
Name to appear on certificate *
Be sure to spell check! We will just copy/paste.
Your answer
Position *
Choose one
Position Description *
If faculty/staff, please list your college/department/unit/program. If student, please list your college/major.
Your answer
Employee or student ID number *
7 digits
Your answer
Email *
Your answer
Phone *
Your answer
Mailing/Street Address *
For CAMPUS MAIL: Please include department, Room # & Building or MMC #, & Campus Delivery Code
Your answer
City, State, Zip Code *
Your answer
Comments:
Your answer
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