Request to Mail Diploma or Cercate
Student ID Name:
Other Name(s) under which you aended
Dates of aendance: From / to /
Major/Degree Plan at me of graduaon:
Address to which the diploma should be mailed: (Post Oce Boxes are not acceptable)
To the Aenon of
Address Line 1
Address Line 2
City State Zip Code
Contact Phone Email
PLEASE NOTE: Your diploma will be mailed using USPS Cered Mail services. Someone must sign for the package when it arrives. Keep this in mind
when lisng the address to which the diploma should be mailed. Addional fees will be assessed to diplomas returned to our oce.
If this request contains an INTERNATIONAL ADDRESS please check here and write the complete address EXACTLY AS IT SHOULD APPEAR on the back
of this form. There is an addional $75 fee for internaonal addresses. LC is not responsible for diplomas that do not arrive.
By my signature I aest that I live more than 50 miles away, and am eligible to request my diploma be mailed to me.
Signature Date
Fee Payment Due:
Fee for not aending
commencement ($100)
(Assessed to Graduate-
Level Students ONLY)
Internaonal address fee
Addional Diploma ($36)
Other: ______
Receipt of payment must be
This area for Oce Use Only