Diploma Reorder Form
Return Request To:
Registrar’s Office
Nazareth College
4245 East Avenue
Rochester, NY 14618-3790
Pl
ease make checks payable to “Nazareth College”
For
more information, call (585) 389-2816
(please print)
(please print)
Former Name (if applicable):
Last 4 Digits of SSN:Name:_________________________________________ _______________
_____________________________________________________________
Street Address:_______________________________________________________________________
City, State, Zip:_______________________________________________________________________
Email:Daytime Phone:__________________________________ ___________________________
Date:Signature:_______________________________________ ____________________________
Diploma Information:
Degree You Received (check one):
BA BFA BS BM MA MS MSE MSW DPT
Dat
e You Graduated (m/yyyy):________________________
PRINT CLEARLY your name exactly as you wish it to appear on your diploma.
(Please clarify punctuation, capitalization, etc.)
First Name Middle and/or Maiden Name Last Name
_______________________________ _______________________ _____________________
Date Requested:_______________
Date Processed:_______________
Paid: $10.00
Cash Check #____________
ID # ______________
Honors:_________________________
