Southern Illinois University School of Medicine

$SIU School of Medicine\$
	Office of Student Affairs

Student Affairs Home Page | Medical Student Web Page

Commencement Information Form

Please fill in the information below so that we will know how you want your name and information to appear on the various documents related to graduation. The only restriction that applies is the class composite. There is only room for your first and last name and a middle initial. Please provide information on your state Senator and Representative. Please contact us if you have any questions.

Please Note: This form must be completed before you arrive to schedule your pictures and/or are measured for your cap and gown.

Please complete all fields. Fields marked with an asterisk are required fields and must be answered. Please TYPE NAME EXACLTY as you wish it to appear on the following:

*Diploma:

*Commencement Program:

*Composite Picture:

*Yearbook:

Please complete the following information which is used for commencement:

Your Hometown - City:	State:	County:
Your State Senator:	District#
Your State Representative:	District#

Pre-Medical School Education: Please list colleges attended with degree(s) earned.
*School	*City, State	*Degree

If you would like a copy of this form, click the print button before clicking on the submit button.

Office of Student Affairs

Commencement Information Form