Summary: 24 Request for Gerontology Certificate| UGA Institute of Gerontology
Request for Gerontology Certificate
Name (as you want it to appear on Certificate) Date
Mailing Address (for Certificate)
Telephone Number (Home) (Work)
Please list the course numbers that have been completed for the Graduate Certificate of Gerontology
Please list the course that was completed for the practicum or research project (3 hours).
Please list the title of your poster and year of its presentation at the Annual Southeastern Student Mentoring
Conference in Gerontology & Geriatrics.
Student's signature Date
Institute of Gerontology Assistant Director's signature Date
Please note that you cannot receive your Graduate Certificate of Gerontology until all classes listed above have
been completed and appear on your transcript, and the final version of your practicum or research project has
been submitted to the Center. An exit interview should also be completed. Please mail this completed form to:
Assistant Director, Institute of Gerontology, 255 E. Hancock Ave., University of Georgia, Athens, GA 30602-