APPLICATION FORM FOR REPLACEMENT OR DUPLICATE DIPLOMA (MUST BE NOTARIZED)

NAME: _______________________________________________ DATE __________________
NAME ON ORIGINAL DIPLOMA: ________________________________________________
SCHOOL, DEGREE, YEAR AND DATE ON ORIGINAL DIPLOMA (AND HONORS IF APPLICAPLE): __________________________________________________________________
REASON FOR REQUEST:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
STUDENT ID NUMBER OR BIRTHDATE: ___________________________________________
MAILING ADDRESS:_____________________________________________________________
________________________________________________________________________________
EMAIL ADDRESS:______________________________________________________________
PHONE NUMBER:______________________________________________________________

IS THE ORIGINAL DIPLOMA ENCLOSED? ____YES ____NO
IF NO, EXPLAIN WHY ___________________________________________________________
________________________________________________________________________________

ENCLOSE CHECK MADE OUT 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 PRESENT.

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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.
SIGNATURE: __________________________________________ DATE___________________
NOTARY: _____________________________________________ DATE___________________
COMMISSION EXPIRATION:_____________________________________________________

RETURN TO:

Jackie Zaltzman, Diploma Coordinator
Office of the Secretary, University of Pennsylvania
211 College Hall
Philadelphia PA 19104-6303
Phone: 215-898-3553
Fax: 215-898-0103
e-mail: zaltzman@upenn.edu

Updated September 2, 2003
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