Assistive Technology Specialist Certificate Request

Assistive Technology Specialist Certificate
Application Form

Please turn in application only if you have completed the program.

I have successfully completed the required courses for the Assistive Technology Specialist Certificate Program and am thereby entitled to receive the certificate.

Students: This certificate application is a record of your achievement. Like a grade report, it provides documentation for the certificate award. After you have completed all requirements, fill in this form and click the Submit Application button below.

Student Information
*Full Name:	[Name as it should appear on the printed Certificate]
*Full Mailing Address:	[Include Street Address, City, State and Zip Code]
*Student ID:
*E-mail Address:
Contact Phone:

Course Information
Required Course(s)	Term Completed
SPE 530 - Introduction to Assistive Technology
SPE 531 - Basic Assistive Technology
SPE 532 - Advanced Assistive Technology
SPE 533 - Administration of Assistive Technology Services
SPE 537 - Capstone Course in Assistive Technology

Student Signature
Initials
Date
I would like to be contacted to provide a review/testimonial about my experience in the program.

Assistive Technology Specialist CertificateApplication Form

Student Information

Course Information

Student Signature

Assistive Technology Specialist Certificate
Application Form