Fillable DIPLOMA RE-ORDER FORM (University of Kansas School of Medicine)

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DIPLOMA RE-ORDER FORM (University of Kansas School of Medicine)

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DIPLOMA RE-ORDER FORM
Office of the Registrar
Mail Stop 4005, 3901 Rainbow Boulevard
Kansas City, KS 66160-7191
PHONE: 913-588-7055 FAX: 913-588-8841
kumcregistrar@kumc.edu
Print Name ________________________________________________________
Student ID: ______________________ DOB:_____________________
Print Official Name for Diploma
First Middle Last Name
*To change your name we need one form of ID attached to the request. Documentation may include a copy of th
e
f
ollowing: driver’s license, marriage license, court order, or social security card.
Degree Received: _______________________________ Year Degree Received _______________
Phone # (_
_____) _______________________
Mailing Address
_____________________________________________
_____________________________________________
Signature___________________________________________ Date __________________
Mailing Option
Amount
Pickup in G035 Dykes Library
$10
Domestic Mail
$20
Certified Domestic Mail
$25
Certified International Mail
$35
Payment Options
Check or Money Order Visa MasterCard
Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Security Code __ __ __ Expiration Date __ __/__ __ Zip Code__ __ __ __ __
Name on Card _________________________________________________
Signature _____________________________________________________
Of
fice Use Only
Date Received: Payment Processed: By:
Other Name:___________________
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DIPLOMA RE-ORDER FORM (University of Kansas School of Medicine)

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Completed 17 July 2021

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