Request for Replacement Diploma

Give a reason for Request.  Please choose one from the list of three below:

          Name Change

(Return original diploma with a copy of marriage license, divorce decree or court noting name change)

          Damaged (Return original diploma)

          Other (Please explain)

Name as it should appear on Diploma

                                                                                                                                                            

(First)                      (Middle)                            (Maiden)                                 (Last)

Name at the time of enrollment

                                                                                                                                                            

(First)             (Middle)                                   (Maiden)                                      (Last)

Student ID Number and Address to which Diploma should be sent (No P.O. Boxes)

Degree (1)                                                                   Date Conferred                        

Degree (2)                                                                   Date Conferred                        

Signature                                                                  Date                                                

Subscribed and sworn to before me this             day of                                  , 20         .

Notary Public Signature / Seal                                              

Please enclose a check or money order in the amount of $  33.00 made payable to Purdue University Calumet and please allow 4 to 6 weeks for processing.

For the PDF version of this page, please click on the following link of  diploma.

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