Fillable Replacement Diploma (Arkansas Tech University)

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Replacement Diploma (Arkansas Tech University)

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OFFICE OF THE REGISTRAR
Brown Hall, Suite 307
REQUEST FOR REPLACEMENT DIPLOMA
Student ID Number
T
Date
Name Enrolled Under (Last, First, Middle, Other)
Date of Birth
Phone Number
___ ___ ___ - ___ ___ ___ - ___ __
Address to Mail Diploma
Student Signature
There is a $25.00 replacement fee for re-ordering your diploma, and payment must be received
before the diploma will be mailed. Credit card payments may be made to Student Accounts by
calling 479-968-0271, or you can mail your payment to the address below.
RINT
OUR
AME
XACTLY
S
OU
ANT IT TO
PPEAR ON
OUR
IPLOMA
(Upper and lower case letters please – no special characters)
Term y
our degree requirements were completed:
Spring
Summer
Major:
Minor:
Second Major:
Number of diplomas: ________________
@ $25.00 each
Total
amount due:
________________
Your request can be submitted by:
Mail—
Arkansas Tech University
Office of the Registrar
Brown Hall, Suite 307
105 West O Street
Russellville, AR 72801-2222
Fax—
479-968-0683
Email
—
graduation@atu.edu
Payment can be mailed to the address above, or you can pay by phone to Student Accounts (479-968-0271).
Revised October 5, 2017
Fall Year:
R
EGISTRAR
’
S
O
FFICE
U
SE
O
NLY
:
Degree:
Honors:
Date Awarded:
Charged (F030):
Paid:
Printed:
Mailed/Picked Up:
Initials:
1
$ 25.00
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Replacement Diploma (Arkansas Tech University)

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Completed 18 July 2020

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