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"text": "KENTUCKY STATE UNIVERSITY",
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"text": "Inspiring Innovation.\nGrowing Leaders.\nAdvancing Kentucky.",
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"text": "Office of the University Registrar\nAcademic Services Building, Suite 323\n400 East Main Street\nFrankfort, KY 40601\n502-597-6234 (Phone)\n502-597-6239 (Fax)",
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"text": "Graduate\nREQUEST FOR REPLACEMENT DIPLOMA",
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"text": "To request a replacement diploma, please complete the information below and enclose your payment of $30.00 made payable to Kentucky State University. For diplomats 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.",
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"text": "Please type or print:",
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"text": "Social Security Number and/or Student ID Number",
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"label": "Name to appear on your new diploma",
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"text": "Social Security Number and/or Student ID Number\nName of your major",
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"text": "Name of your degree (B.A. B.S., M.A., etc",
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"text": "Daytime phone number/Cell number: (ex. 999-999-9999)",
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"text": "___",
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"text": "Please send the diploma to:",
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"text": "Please send the diploma to [2]",
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"text": "Please send the diploma to [3]",
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"label": "Please send the diploma to [3]",
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"pdf_field_type": "Text",
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{
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"text": "Please send the diploma to [4]",
"field_kind": "text",
"label": "Please send the diploma to [4]",
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"pdf_field_type": "Text",
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{
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"type": "FORM_FIELD",
"location": {
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"text": "Date",
"field_kind": "text",
"label": "Date",
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"text": "Signature",
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{
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"text": "Signature Date\nCost of Replacement: $30.00 (includes standard shipping charges)",
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{
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![\"Image\"](\"imgs/img_in_image_box_16_22_166_116.jpg\")
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