Updated: 7/20/16
*All information marked with an asterisk (*) is required.
*SS# OR Student ID#: _________________________ *Date of Birth: ______________________
*Last Name: _______________________________ *First Name: ________________________
Former Name(s): _____________________, _____________________
Current Mailing Address: _________________________________________________________
City: ___________________________State: __________________ Zip Code: ______________
*Telephone Number (____) __________ - __________
Email Address: ___________________________________________
*Degree Received: ____________________________________________________
*Graduation Date: ______________________
*Major: ________________________________ Minor: ________________________
Student’s Original Signature (required): ___________________________ Date: _____-_____-_____________
AUTHORIZATION TO CHARGE CREDIT CARD
REQUESTED INFORMATION
Name on Card Daytime Phone Number
( ) -
Amount
$ 50.00
Address Card # Expiration Date
City, State, Zip Signature Date
Fairmont State University
Diploma Replacement Form
Request must be made in writing. Request from students who have financial holds on a student account will not be
processed. A $50.00 payment must accompany your request.
Mailing Address: Fairmont State University,
ATTN: Enrollment Services, 1201 Locust Avenue, Fairmont, WV 26554
Fax: (304) 367-4789; Email: enrollmentservices@fairmontstate.edu
Office use ONLY:
Fee Paid: __________
- -
