Completed By:
Employee name: ______________________________________________
Signature: ____________________________________________________ Date: _____________
Replacement Diploma Form
The Replacement diploma fee is $65.00, payable by money order, credit card, or cashier’s
check to Fisk University. Please note, you may contact the Business Office at 615-329-8546
to make the payment via phone using a Visa or Master Card or supply the information
below. This fee must be paid before the diploma is ordered. Processing and delivery of the
diploma is handled through the Office of the Registrar and generally takes up to six weeks
to receive. If you choose to fax, please send to 615-329-8891
Alumni/Student Information
Name on original diploma: ___________________________________________________________
Current Name (If different from above) ________________________________________________
Current Mailing Address: ____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Degree Received (B.S., B.A., M.A.): _____________________________________________________
Date of Graduation: ____________________
Student ID/SSN: _______________________ Phone Number: ____________________________
Email Address: _______________________________________________________
Order and Billing Information
Quantity ordered____ Hold diploma for pick-up please call when ready
Mail Diploma to address above Phone Number: ______________________________
Mail to Different Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Fisk University Business Office
1000 17
th
Avenue North
Nashville, Tennessee 37208
Phone:615-329-8546
Fax: 615-329-8520
1000 17
th
Ave North
Nashville, Tennessee 37208
Phone: 615-329-8586
Fax: 615-329-8891
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