Replacement Diploma Request Form

Student/Degree Information:

Name:_______________________________________________________________________________________________
First MI Last

Student ID# or SSN:________________________________

Name at time of graduation:_______________________________________________________________________________
(if different from above)

Date of Birth:________________________________
MM/DD/YYYY

Phone Number (required):____________________________________________

Email (required):____________________________________________________

*Name desired on diploma:____________________________________________________________________________
*YSU must have the diploma name on record. If the diploma name is not on record you must submit a Change of Information form and appropriate documentation with this form.

Degree Received:____________________________ Graduation Date:__________________________
Did you receive honors? ___Yes ___No

Please check one of the following:

___ My original diploma was lost, damaged, or destroyed. ___ My name is different than the one on my diploma.
___ My original diploma was never received. ___ I need a replacement diploma for an apostille.
___ Other:_________________________________________________________________________________

Delivery/Pick-Up Information:

Diploma can be picked up at the Penguin Service Center (330-941-6000) in Meshel Hall 2^nd floor, during regular business hours. A photo ID must be presented for pick-up.

___ I will pick-up my diploma. Please (circle one) call or email me when it is ready.

___ I cannot pick-up my diploma. I authorize,___________________________________, to pick up my diploma for me.

___ Please mail the diploma to:
Address:_______________________________________________________________________________________
City:___________________________________ State__________________________ Zip:_____________________

Student Signature:_______________________________________________ Date:____________________________