Request for Replacement/Additional Diplomas
Credit/Debit Card Form Date: _____________
PLEASE MAIL OR FAX THIS FORM TO:
University of Hawaii at Hilo
Office of the Registrar
200 W. Kawili Street
Hilo, HI 96720-4091
Fax (808) 932-7448
1. Fill out Student Information:
Semester: Fall Spring Summer Year: ________________
Name:
___________________________________________________________________________________________________________
(Print) (Last) (First) (M.I.)
Address:
___________________________________________________________________________________________________________
Street/PO Box City/Province State/Country Zip Code
Phone Number: _____________________________ Student ID#: __________________________________
Email Address: _____________________________________________________
2. Fill out Cardholder Information
Name: ___________________________________________________________________________________________________
(As printed on Card)
Billing Address: _________________________________________________________________________________________
Street/PO Box City/Province State/Country Zip Code
Phone Number: ________________________________ Card Issuer (Check only one): Visa
Mastercard
Amount: $ ________
Credit/Debit Card Number (16-digits):_________________________________________________________________
Expiration Date: ____________________ Card CV2 Code (
3-digit code on back of card):_______________
To Student:
•
This form may be used if paying for a Replacement/Additional Diploma Fee by credit or debit card
• Do not use this form if you are paying with a check or money order
•
Non-Refundable Fees are subject to change
I agree to pay the non-refundable fees that are indicated on the graduation application
Cardholder Signature _____________________________________ Date: ________________
