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# KENTUCKY STATE UNIVERSITY

Inspiring Innovation.

Growing Leaders.

Advancing Kentucky.

# Undergraduate REQUEST FOR REPLACEMENT DIPLOMA

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



Name to appear on your new diploma

Social Security Number and/or Student ID Number

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:



Signature                                      Date

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

Method of Payment: Check



Money Order