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# KENTUCKY STATE UNIVERSITY

Inspiring Innovation.

Growing Leaders.

Advancing Kentucky.

# Graduate REQUEST FOR REPLACEMENT DIPLOMA

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 anew 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:30.00 (includes standard shipping charges)

Method of Payment: Check



Money Order