LOCK HAVEN UNIVERSITY - REQUEST FOR REPLACEMENT DIPLOMA
• If your diploma has been damaged or lost, please use this form to request a replacement. A note will be printed on the
diploma indicating “replacement diploma.”
• All requests for a replacement diploma must be submitted using this form
• There is a $25 diploma replacement fee which must be paid before submitting the request form. Payment is made online
by selecting the link on the instructions page.
• Processing time is at least 10-14 days; during peak periods the processing time may take longer
• PRINT LEGIBLY; submit a copy of your payment confirmation with this form.
Name________________________________________________________________ Date of Birth___________________________
Last First Middle
LHU Student ID________________________________ Social Security Number___________________________________________
Note: SSN is needed only to locate your records if you provide an incorrect LHU ID or do not remember your LHU ID.
Current Address ______________________________________________________________________________________________
Street Address/PO Box City State Zip Country
Daytime Telephone (
requ ired) ___________________________________________________________________________________
Name on Original Diploma
_______________________________________ ____________________________ _____________________________ _________
First Middle Last Suffix
Degree (check one) ___ Master of Education ___Master of Health Science ___Master of Liberal Arts ____Master of Science
___Bachelor of Arts ___Bachelor of Fine Arts ___Bachelor of Science
___Bachelor of Science in Education ___Bachelor of Science in Nursing
___Associate of Arts ___Associate of Applied Science ___Associate of Science ___Associate of Science in Nursing
Graduation Date (month) _____________________________ (year) ___________________________
Name and Address You Would Like Diploma Mailed To:
_____________________________________________________________________________________
Name
_____________________________________________________________________________________
Street
_____________________________________________________________________________________
City State Zip Country
____________________________________________________________ ________________________
Student’s Signature Required Date
RETURN COMPLETED FORM AND COPY OF PAYMENT CONFIRMATION TO:
Registrar’s Office
Ulmer Hall 224
L
ock Haven University
Lock Haven PA 17745
Fax: 570-484-2734
last updated 10/29/2014
