To receive a duplicate copy of your Associate’s degree diploma or Technical Certificate, please complete this form
and submit it, along with your payment of the $25.00 fee, to Southern University at Shreveport Registrar's Office.
Submit one form for each requeste duplicate diploma and/or certificate. The fee may be paid in person with cash,
money order, or credit/debit card or mail this form, with a money order payable to Southern University at Shreveport,
ATTN: Registrar’s Office, 3050 Martin Luther King, Jr. Drive, Shreveport, Louisiana 71107.
According to our present policy, all duplicate diplomas show the date the degree was originally conferred and bear the
signatures of the o
riginal University officials. The name to appear on the duplicate diploma will be that which appears
on University records. If your reason for ordering the duplicate diploma is that you have had a change of name,
please indicate your new name as requested below. Please attach a completed Change of Name and/or Address form
with the required documentation.
Y
our duplicate diploma and/or technical certificate will be mailed to you at the address listed below. Please allow up to
thirty (30) business days (not including weekends or holidays) for your duplicate diploma/certificate request to be
processed.
Name as listed on University records:
L
ast Name First Name Middle Initial Maiden Name
N
ame as it should appear on diploma:
Last Name First Name Middle Initial Maiden Name
D
ate of Birth: Last 4-digits of SSN SUSLA ID #
9000
M
ailing Address:
Street City ST Zip
T
elephone: E-mail @
Date of Graduation: Delivery Method: will pick up diploma mail diploma
Re
ason for Request: lost damaged incorrect other
Please note that the approximate delivery time is 2–4 weeks.
S
tudent’s Signature: Date:
Registrar’s Office
Duplicate Diploma Request
REGISTRAR’S OFFICE USE ONLY
Received Date: __________ Mailed Date: __________ Picked-Up Date : __________ Payment information: cash
money order
RO:
Duplicate Diploma Request: Revised 1/14:TJ: 07/14:LR: 07/15:LR
DEGREE EARNED: (CHECK ONE) AAS ___ AGS ___ AS ___ CTS ___ CAS ___ TD ___
Major Second Major (if applicable)
Concentration Second Concentration (is applicable)
3050 Martin Luther King, Jr. Drive Phone: (318) 670-9229
Shreveport, Louisiana 71107 FAX: (318) 670-6344
www.susla.edu
registraroffice@susla.edu
