Duplicate Diploma Request Form
OFFICE OF THE REGISTRAR 101 N. College Avenue Annville, PA 17003-1400 (717) 867-6215 | Fax (717) 867-6018 www.lvc.edu/registrar
DUPLICATE DIPLOMA REQUEST *Please note: reprinted diplomas will have the signatures of the current President, Dean, and President of the Board which may not be an exact duplicate of the original diploma.
PERSONAL INFORMATION Student ID or SSN: ____________________ Name: _________________________________________________________ Last First Middle Date of Birth: ________________________ Maiden Name(s): _________________________________________________ Home Address: ______________________________________________________________________________________ __________________________________________________________________________________________________ Phone Number: ___________________________ Email Address: _____________________________________________ My Graduation Date Was:
______ /______ Month Year
Degree(s): _________________________________________
PROCESSING INFORMATION
□
Please mail my diploma to the following address:
_______________________________________________________________________________ _______________________________________________________________________________ City: __________________________ State: ________ Zip: _____________ Country: ___________________ Processing Options:
□ Standard ($35) □ Express ($65) □ Priority ($110) □ Priority International ($160)
6 to 8 weeks 10 to 14 business days 2 to 4 business days 3 to 5 business days
SIGNATURE (REQUIRED TO PROCESS THIS REQUEST) I authorize the release of my diploma as directed above: _________________________________________________________ ______________________ Signature (Must be signed by the record holder) Date ___________________________________________________________________
PAYMENT OPTIONS (If using a credit card, this section must be removed and shredded after processing by the Business Office)
□ Check or Money Order (enclose in envelope) Payable to: Lebanon Valley College □ Credit Card Authorized Amount $_________ Acct. # _________________________ Address: ___________________________________________________ ___________________________________________________
Exp. Date ______/______ Security Code: ____________
DUPLICATE DIPLOMA REQUEST *Please note: reprinted diplomas will have the signatures of the current President, Dean, and President of the Board which may not be an exact duplicate of the original diploma.
PERSONAL INFORMATION Student ID or SSN: ____________________ Name: _________________________________________________________ Last First Middle Date of Birth: ________________________ Maiden Name(s): _________________________________________________ Home Address: ______________________________________________________________________________________ __________________________________________________________________________________________________ Phone Number: ___________________________ Email Address: _____________________________________________ My Graduation Date Was:
______ /______ Month Year
Degree(s): _________________________________________
PROCESSING INFORMATION
□
Please mail my diploma to the following address:
_______________________________________________________________________________ _______________________________________________________________________________ City: __________________________ State: ________ Zip: _____________ Country: ___________________ Processing Options:
□ Standard ($35) □ Express ($65) □ Priority ($110) □ Priority International ($160)
6 to 8 weeks 10 to 14 business days 2 to 4 business days 3 to 5 business days
SIGNATURE (REQUIRED TO PROCESS THIS REQUEST) I authorize the release of my diploma as directed above: _________________________________________________________ ______________________ Signature (Must be signed by the record holder) Date ___________________________________________________________________
PAYMENT OPTIONS (If using a credit card, this section must be removed and shredded after processing by the Business Office)
□ Check or Money Order (enclose in envelope) Payable to: Lebanon Valley College □ Credit Card Authorized Amount $_________ Acct. # _________________________ Address: ___________________________________________________ ___________________________________________________
Exp. Date ______/______ Security Code: ____________
