Request for ADR Certificate

YOU MUST HAVE SUCCESSFULLY COMPLETED THE 3 REQUIRED CLASSES LISTED BELOW & AT LEAST 1 OF THE ELECTIVE CLASSES AND GRADES MUST BE FINAL BEFORE YOUR REQUEST WILL BE PROCESSED.

Instructions:

1. Complete the information above the line by filling in all blanks in the table.

2. Sign and date the request.

3. Select one option below the signature line.

4. Return completed form to the Institute of Applied Economics:

Please print or type responses in space provided.

Name:_________________________________________________________________________
(This is how your name will appear on the Certificate.)

Student ID:______________________________  (not SSN)
Daytime Phone:__________________________
Courses and Semester completed for Certificate:

Courses

 Semester Registered

Required Courses:


AECO 4000 - Mediation
______________________________________


AECO 4420 - Practicum
______________________________________


AECO 4120 - Negotiation
______________________________________

Elective Course: (You must check at least 1)

 Semester Registered


_____ AECO 4010 - Family Mediation
 

_____ AECO 4020 - Workplace ADR		  

_____ AECO 4030 - Global Workplace Dispute Resolution
 

_____ AECO 4040 - Crisis Intervention
 

_____ AECO 4450 - Arbitration		  
Other AECO course. Please specify:

__________________________________________________________
 

 

______________________________________              ______________________________
Signature                                                                            Date

(check one)

_____ I will pick up my certificate from the department office located on the UNT Denton Campus, Chilton Hall, Room 263.  Please contact me by phone or e-mail at _____________________________________________________________ when the certificate is ready.
_____ Please mail the complete certificate to me at _________________________________________

___________________________________________________________________________

PLEASE NOTE: Certificates are prepared and mailed three times per year after the end of each spring, summer, and fall semester. Request forms need to be submitted as soon as possible at the end of the semester in which all courses required for the certificate are completed. Date guidelines for submitting request forms for certificates are:

Semester all 
Classes Completed		 Request Form
Due*		 Certificate
Ready*
Spring June 1st June 15th
Summer Sept. 1st Sept. 15th
Fall Jan. 20th Feb. 5th

*While we will strive to meet these dates, actual dates may be up to two weeks later than those listed because of other deadlines and workload.

If you have any questions when completing this form, please contact the Dr. McKee by phone at (940) 565-3437 or in person in Chilton Hall, Room 263.