Application Form for a Replacement or Duplicate Diploma

(Form Must Be Notarized)

Complete this form and send it and payment to:

Diploma Coordinator

Office of the University Secretary

University of Pennsylvania

1 College Hall, Room 211

Philadelphia, PA 19104-6303

Name: _______________________________________________________ Date: ___________

Name on Original Diploma ______________________________________________________

Degree Information

School: _______________________

Degree: _______________________

Year: _________________________

Reason for Request______________________________________________________________

Is original diploma enclosed? ___________If not, explain why____________________________

Student Id Number (not Social Security Number): _____________________________________

Date of Birth: __________________________________________________________________

Mailing Address: _______________________________________________________________

Email Address: _________________________________________________________________

Tele No.: _____________________________________________________________________

Please Send to (If Not Your Own Address):

______________________________________________________________________________

Fee: Check or Money Order in US Dollars, we cannot accept credit cards for payment, payable to: “Trustees of the University of Pennsylvania”

____ $75 for each replacement diploma dated prior to May 1990

____ $100 for each duplicate diploma dated May 1990 to the present

I hereby certify that the above statements are true.  I understand that The University of Pennsylvania reserves the right to institute any appropriate legal or other proceedings for misrepresentation of the information stated above or in case of fraud.

STUDENT SIGNATURE _______________________________ DATE ___________________

NOTARY SIGNATURE ________________________________ DATE ___________________

COMMISSION EXPIRATION ____________________________________________________