Fillable Form Otr178 - Duplicate Diploma Request printable pdf download

DUPLICATE DIPLOMA REQUEST

RETURN FORM:

By mail to:

DIRECTIONS—

Diplomas

Graduates of the University of Minnesota may order multiple

160 Williamson Hall, 231 Pillsbury Dr.

copies of their diplomas for $15 per copy. Duplicate diplomas can be ordered only after

SE, Minneapolis, MN 55455

the original diploma is received and are mailed two to three weeks from receipt of order.

On campus at:

160 Williamson Hall

If you will be working or continuing your studies abroad and this diploma will require an

By fax (if paying by credit card):

Apostille, please contact the Office of the Registrar at 612-624-9720.

612-625-4351

To ensure privacy online, open in Adobe Reader (free at ). Please add the required signature(s) in blue or black ink.

SECTION 1. Student information

NAME AS IT IS TO APPEAR ON THE DIPLOMA (please print clearly). If you are requesting a diploma name that differs significantly from the name on your

records, you must submit documentation. For more information, contact the Office of the Registrar, 612-624-9720.

First

Middle

Last

Daytime phone number

Email address

Date of birth

University ID or SSN

Student signature (required)

Date

SECTION 2. Diploma information

Diploma mailing address (line 1)

Recipient name

Diploma mailing address (line 2)

City

State

ZIP code

Country

Recipient’s daytime phone number (required for Priority Overnight or International Priority deliveries)

PART A. Diploma #1

College

Degree

Honors

Graduation date

PART B. Diploma #2

College

Degree

Honors

Graduation date

SECTION 3. Order summary

Delivery method (all methods require 2-3 week processing time)

Quantity

Cost

Total

Regular service (Sent via U.S. mail; Allow sufficient time for delivery by U.S. Mail, with up to

$15 each duplicate diploma

three weeks or more for international mail.)

Priority Overnight (Next-business-day delivery by 3 p.m. to most U.S. addresses; recipient

$15 each duplicate diploma, plus

phone number is required and this method cannot be made to P.O. boxes.)

$15 delivery fee for each address

International Priority: (2-5 business day delivery time; recipient phone number is required

$15 each duplicate diploma, plus

and this method cannot be made to P.O. boxes.)

$25 delivery fee for each address

Total diplomas requested:

Total amount due:

SECTION 4. Payment information

Requests will not be processed without payment. Send check or money order payable to the University of Minnesota, or provide credit card information

(Visa, MasterCard, Discover, Diner’s Club, AmEx) with card number and expiration date. NOTE: Overpayments of $5.00 or less will not be refunded.

Check one method of payment

Amount enclosed

Cash (in-person orders only)

$________________

Check or money order payable to the University of Minnesota

$________________

Visa

MasterCard

Diner’s Club

Discover Card

AmEx

$________________

__ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __

__ __ / __ __

Account #

Expiration date

To request copies of this form in an alternative format, please call a Disability Resource Center liaison at

*OTR178*

612-625- 9578. The University of Minnesota is an equal opportunity employer and educator. This form is

printed on paper made from no less than 20 percent post-consumer waste.

Please recycle.

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Form Otr178 - Duplicate Diploma Request

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