Inspiring Innovation. Growing Leaders. Advancing Kentucky.

Office of the University Registrar Academic Services Building, Suite 323 400 East Main Street Frankfort, KY 40601 502-597-6234 (Phone) 502-597-6239 (Fax)

To request a replacement diploma, please complete the information below and enclose your payment of $20.00 made payable to Kentucky State University. For diplomas to bear a new legal name after the degree has been awarded, legal documentation (i.e., copy of marriage certificate, divorce, or other court document) must be submitted along with this application. The replacement will carry the titles and signature of current University and Board of Regents officials. Please allow up to four (4) weeks for delivery.

Please type or print:

Name as it originally appeared on your diploma

<div style="text-align: center;"><img src="imgs/img_in_image_box_0_1_1069_92.jpg" alt="Image" width="99%" /></div>

Name to appear on your new diploma

Social Security Number and/or Student ID Number Name of your major

Name of your major

Name of your degree (B.A. B.S., M.A., etc.)

Graduation Date (Month, Year)

Daytime phone number/Cell number: (ex. 999-999-9999)

Please send the diploma to:

___ <table><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr></table>

Signature Date Cost of Replacement: $20.00 (includes standard shipping charges)

<div style="text-align: center;"><img src="imgs/img_in_image_box_16_22_166_116.jpg" alt="Image" width="81%" /></div>

Method of Payment: Check | Money Order

<div style="text-align: center;"><img src="imgs/img_in_image_box_17_18_168_115.jpg" alt="Image" width="80%" /></div>