Print page, complete, sign, and return with the $20 fee (per diploma) to the address below.
Please print your name exactly as you want it to appear on your diploma.
University Policy Regarding Diploma Name
Graduate Information:
| First name or initial: | |
| Middle name or initial: | |
| Maiden name (if you wish): | |
| Last name: | |
| Student ID (BearPass Number or SSN): | |
| Name at time of graduation (if different from above): |
|
| Semester and year of graduation: |
Mailing Address:
| Street/PO Box: | |
| City, State, Zip: | |
| Daytime Telephone Number: | |
| Email Address: |
Check here if you do not wish for us to share your mailing address with the Alumni Office.
Check here if you do not wish for us to update your address on your permanent records.
| Date: | Signature: |
Check here if you want a Missouri State University diploma cover for an additional $10 fee (total of $30 for diploma and diploma cover). Photo of a diploma cover.
Send this form, along with a check or money order for $20 or $30 (payable to Missouri State University) to: Missouri State University, Office of the Registrar, ATTN: Reissued Diploma, 901 S. National Ave., Springfield, MO 65897. No cash please.
Please allow 8 weeks for delivery. Call (417) 836-5520 if you have any questions or special instructions.
Office Use
| Date Received: | Date Deposited: | Check - Money Order |