Revised: 08/07/18
DIPLOMA RE-ORDER FORM
STUDENT INFORMATION
Full Name ________________________________________________________ Date of birth __________________
Former Name(s) ______________________________________________ SS/Student ID# _____________________
Address ________________________________________ City _________________ State _______ Zip:__________
Home Phone _____________________________________ Daytime Phone __________________________________
Currently enrolled? Yes No Approximate Year of Attendance __________________________________
I authorize LCSC to send my Diploma to the Address Listed Above.
Student Signature: Date:
DIPLOMA INFORMATION
Name _________________________________________________________________________________
*PRINT OR TYPE NAME AS YOU WISH IT TO APPEAR ON YOUR DIPLOMA*
Degree
BA BS BSN BSW BAT BAS BASAT
AA AS AAS ATC CERT
Major _________________________________________________________________________________
Honors
summa cum laude magna cum laude cum laude Presidential Honors
*Signatures printed on the diploma will be for the current President of Lewis-Clark State College and the current
President of the Board of Trustees.
PAYMENT INFORMATION
Standard Processing: $25.00 per Diploma. Please allow 1-2 days for processing ($25.00 + 2.5% = $25.63 if
using a credit card).
Express Delivery: $35.00 per Diploma. Rush overnight delivery must be received by 11 am to be processed
that day. ($35.00 + 2.5% = $35.88 if using a credit card).
You must include check, money order, cash, or credit card information with order form. Diplomas will not be
processed without payment. For credit card transactions ONLY there will be a 2.5% fee.
CHARGE: A/E VISA M/C DISCOVER #: _________/__________/__________/___________
V-Code #: ______ Expiration Date: ____________
The v-code is a three digit number after the credit card number on the back of some cards.
click to sign
signature
click to edit
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