REPLACEMENT DIPLOMA REQUEST

REPLACEMENT DIPLOMA REQUEST
Student Name: _____________________________________________________________________________
Last
First
Middle
Student ID (if available): _____________________________Birth Date: _____________________________
Previous Name(s) __________________________________________________________________________
Would you like the Replacement Diploma to indicate your new name? If so, please also complete a Name
Change Form located online at http://www.lssu.edu/registrar/documents/NAMECHANGEFORM.pdf and
submit the form with this request.
Permanent Address: ________________________________________________________________________
________________________________________________________________________
Phone Number: ____________________________________________________________________________
Degree(s) Awarded: ________________________________________________________________________
Year Awarded: _________________ Number of Diploma’s required: _______________________________
(to be sent to the address above)
Student Signature: ___________________________________ Date: ___________________
Requests can NOT be processed without your signature
This form can be mailed, faxed, or emailed to the Registrar’s Office
Registrar’s Office- Graduation
Lake Superior State University
650 W Easterday Avenue
Sault Ste Marie, MI 49783
Phone: (906) 635-2682 Fax: (906) 635-6202
Email: [email protected]
Office Use Only:
Process Date: ______________
Initials: ___________________
The cost of each Diploma requested is $20.00. Please choose method of payment and complete appropriate
information:
Enclosed please find my check in the amount of _________.
Please bill my credit card:
Visa
MasterCard
Discover
American Express
Name on Credit Card: _______________________________________ Amount to be billed: _______________
Please Print
Credit Card Number:________________________________________ Exp. Date: _______________________