Duplicate Diploma Request Form
Office of the Registrar Phone: 217-581-3511
600 Lincoln Ave Fax: 217-581-3412
Charleston, IL 61920
E-Number: _______________________________ A copy of a Photo ID is Required.
(If unknown, leave blank)
Name (Last, First, Middle): _____________________________________________________
Phone number: _________________________ Email address:_______________________
Alternate Last Name(s) (Ex. Maiden): _____________________________________________
Date of Birth (MM/DD/YYYY): ___________________________________________________
Degree/Major: _______________________________________________________________
How would you like your name to appear on your diploma?
____________________________________________________________________________
Where would you like your diploma sent?
____________________________________________________________________________
____________________________________________________________________________
There is a $25 fee for duplicate diplomas. How would you like to pay?
Duplicate Diploma requests are normally processed within 3 – 5 business days.
Student’s Signature: ___________________________________________________
___ Cash ___ Check/Money Order ___ Credit/Debit Card
_________________________________ ______ /_________
Credit/Debit Card Number Exp. Date (MO/YR)
___________________________________________________
Signature of Card Holder (If the student is not the card holder)
