Replacement Diploma Request Form

Replacement Diploma Request Form
All financial obligations to the university must be cleared before a replacement diploma will be released. Please allow 1-2business
days for processing. In-person pickups will be contacted by phone when the replacement diploma is ready for pickup in the Student
Business Center. Use separate forms if you are ordering replacement diplomas for different degrees.
Please TYPE or PRINT legibly in the spaces below. If this form is not filled out completely, delays may result.
Last Name ________________________________ First Name ___________________________________ MI ______________
Other names used ____________________________
Student ID Number (if unknown, use SSN) _______________________
Current Address ___________________________________________________________________________________________
City ___________________________________ State _______ Zip _____________ Contact Number ( ____ ) ________________
Check this box if you would like the university to update your name and mailing address with the above information.
Degree/Major on diploma ____________________________________________________________________________________
In the space below, please enter your name exactly as you would like it to appear on your diploma:
Student signature for release of diploma__________________________________________________Date_______________
Recipient Information: (Please choose only one of the following)
In-person pick up.
I am currently unable to personally pick up my replacement diploma. I hereby authorize
______________________________________________________________ to pick up this diploma on my behalf.
First Name
Last Name
Please mail to the address I entered above.
Payment Information
$20 fee per replacement copy of diploma: pick up or mailed.
Number of copies _______ x $20 = ____________
________Check or Money Order (enclosed) ________Credit Card:
Account Number ___________________________________________________________________________________
Expiration Date: _____________________ 3-digit Security Code (located on the back of the card) ____________________
Name of Cardholder (as it appears on the card) _____________________________________________________________
Card Holder’s Mailing Address:
Street_________________________________________ City ____________________ State ____________ Zip _________
Signature of cardholder (if different than student) __________________________________________________________
If Faxing:
Fax to: 740-351-3435
Attn: Student Business Center
Use MasterCard, Visa, Discover
If Mailing: Shawnee State University
Attn: Student Business Center
940 Second Street
Portsmouth, OH 45662