Last Updated: 10/25/2018
Name _______________________________________________________ Date _________________
Former Name(s) ____________________________________________________
EMPL ID# ______________________________
Address _____________________________________________________________________________
Street City Zip
Country ________________________________ Phone ___________________________________
There is a $25.00 order fee per diploma.
Cash
Check
Credit Card (Contact the One-Stop to make a card payment over the phone. 701-483-2090)
Number of additional diplomas desired _________
Total amount due ____________
This form may be mailed, faxed, delivered, or emailed to Academic Records.
Phone: 701-483-2536 Fax: 701-483-2409 Email: dsu.records@ndus.edu
Mailing Address: Academic Records, 291 Campus Drive, Dickinson ND 58601
Completed by Name ____________________________________________________ Date ______________________
Name as to appear on the diploma _________________________________________________
Degree _______________________________________________________________________
Major ________________________________________________________________________
Honors Received (if any) _________________________________________________________
Year Graduated ________________
