Diploma Copy Request Form

Diploma Copy Request Form Diploma copies are printed on plain white 8.5 x 11 paper. Official copies include seal, certification, and registrar’s signature and are only available via mail or pick up in person. Unofficial copies can be emailed or faxed, but will not include the official seal. Diploma copies are often used to provide proof of degree for licensure or employment. There is a one-time $15 fee for diploma copies. Contact the Office of the Registrar if you have any questions.

Page 1 of 1 Other Names Used While Enrolled at UNTHSC

Student ID (Optional)

Social Security Number (Optional)

Date of Birth [Required]

School/Program Attended [Required] [ [ [ [ [ [

] Texas College of Osteopathic Medicine ] Graduate School of Biomedical Sciences ] School of Public Health ] School of Health Professions - Physician Assistant ] School of Health Professions - Doctor of Physical Therapy ] System College of Pharmacy

Graduating Year [Required] Valid input: - Numeric - ex: 1111 - can not contain any punctuation. - can not contain any spaces. - must be between 4 and 4 characters.

Pick up in Office Please bring a photo ID to the front desk of Student Affairs for diploma pick up. Student Affairs is located on the 2nd floor of the Carl E. Everett Education & Administration building on 3500 Camp Bowie Blvd. How many diploma copies would you like to pick up in the office?

Mailed How many would you like mailed?

Mailing Address:

Pick up at Graduation For currently enrolled clinical students only How many diploma copies would you like to pick up at the graduation ceremony?

Fax (Unofficial Only) Please list all fax numbers that your diploma copy needs to be sent to: Page 1 of 2 · Diploma Copy Request Form

Attn:

Fax Number:

Any additional fax numbers:

Email (Unofficial Only) Please enter all email addresses where you would like a diploma copy sent:

Diploma Copy Fee There is a one-time $15.00 fee for diploma copies. Once this one-time $15 fee is paid, alumni can request as many copies as needed. Contact the Office of the Registrar to find out if you have paid the fee. Diploma Copy Fee If you have paid the one-time fee, please change the quantity below to 0.

$15.00 each Default: 1 Valid input: - Positive whole numbers

Electronic Signature Signature [Required] I certify that I am the person whose name appears on this form, and do hereby authorize release of my academic records (diploma copy) via the method listed above.

Valid input: - Select only one choice. [ ] I Agree By typing your name below, this serves as an electronic signature for this form. The signature below must match the name on the credit card used for payment. [Required]

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