UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration Replacement/Duplicate Diploma Request
Please complete, print (see "Print Form" button above), sign, and return this form to the Office of Records and Registration, University Hall,
One University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Please be sure to carefully complete all information prior to printing the
document.
Last Name First Name
UIN
Mailing Address
City State Zip Code
Daytime Phone
Records (217) 206-6709 Degree Audits (217) 206-6173 Registration (217) 206-6174 Graduation (217) 206-7730
Student Signature (Required) Date
Email Address
*The name on your diploma must be your official name in our database or listed as a previous name. If the name you want on your diploma is
not in our database, you must officially change it with the Office of Records and Registration before it can be printed on your diploma.
Information about name changes can be found on our website at: http://www.uis.edu/registration/records/NameChangeInformation.html.
If you have questions about this process, please contact the Office of Records and Registration by calling 217/206-6709 or by emailing
registrar@uis.edu.
For Office Use Only
A $30.00 fee is charged for a replacement diploma. Payment may be made by enclosing a personal check (made out to UIS) or money
order. NOTE: Cash cannot be accepted for payment.
Previous Name (If Applicable)
8-21-17
Name to be printed on diploma*
or
and
Date of Birth (mmddyyyy)
Degree**
**If you graduated from Sangamon State University (prior to Summer 1995) and want to request a UIS diploma, you will need to contact the
Office of Advancement. Information about this Diploma Certificate can be found on their website at: http://www.uis.edu/advancement/.
Degree
Award Date Honors
Holds:
Yes No
Payment Ordered
Last Semester Attended Last Year Attended
Middle Name
