Fee $15.00
G:\AR\30 - RECORDS & REGISTRATION\02 Documentation_How to Guides_Training Materials\Forms\Student Forms Revised 01/23/2014
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Form
Enrollment Management
Records and
Registration
One University
Drive
Camarillo, CA
93012
Phone:
(805)
437-8500
Request for Duplicate Diploma
Diploma Fee: $15.00 per duplicate
Copies Requested
Student ID:
Name:
Date of Birth:
Last Name Fi
rst Name Middle Name
Your name on your duplicate diploma will appear exactly as it does on your original diploma. If your name has changed
since the issue of your original diploma, please submit a Name Change Form to Enrollment Management.
Phone: E-mail:
Address: City: State: Zip:
Term Graduated:
Degr
ee Earned:
BA BS
MA MS
M
BA
Major: Concentration/Emphasis:
Diplomas will be sent to the mailing address on file with the University. Please verify your mailing address at CI
Records (myci.csuci.edu). If you need to update your mailing address, but are unable to access online, please
complete the change of address section below. Duplicate diplomas will be mailed within 4-6 weeks.
CHANGE OF MAILING ADDRESS
New Address New Phone Numbers
Street:
Zip Code:
Home Phone:
City:
Cell Phone:
State:
Business Phone:
Please complete and submit this form to the Student Business Services window in the Enrollment Center,
Sage Hall, with appropriate fee. If you have any outstanding obligations to the University this request will not
be processed until they are resolved. Records cannot be released without the written consent of the student,
so please be sure to sign this form below.
Student's Signature Date
Administrative Use Only- Enrollment Management / Student Business Services
Check Cash
By:
Date:
(Student Business Services)
***PLEASE SEND COMPLETED
APPLICATION
TO
RECORDS AND REGISTRATION
FOR PROCESSING***
Administrative Use Only- Records & R egistration
Processed
by: PS
Update:
Student Notification:
(Staff Initials) (Date)
(Date)
