Replacement Diploma Request

Mail or Fax orders to:

University of Massachusetts Lowell
Office of the Provost
Cumnock Hall
One University Ave.

Lowell, MA 01854-3629
Fax: 978-934-5330
 

 

* Please print this form and fill in all information.
* Mail completed form to above address with a check for $25.00 made payable to UMass Lowell.
* Please use a separate form for each diploma request.
* The major will not appear on the diploma -- only the degree received.

* All replacement diplomas are University of Massachusetts Lowell diplomas.   Replacement diplomas with the name of any predecessor institution are not available.

Name:  

 

___________________________________________________________    ____/  ____/  ____

first                     middle               maiden                 last                                                                       Today's date:

Name to Appear on Diploma:  

____________________________________________              ____/  ____/   ____

first                     middle                   last           date of graduation

Social Security Number:  ______ _____ ______

Degree: _____________  Major:  _________________ 

Day

Evening

Graduate

Summa Cum Laude

Magna Cum Laude

Cum Laude

 

Home Address:  _________________________________________________________

City:  _______________     State: ____             Zip:  _______    
Daytime Phone:  ( _____ ) ________ - __________ 
Work Phone:       ( _____ ) ________ - __________      E-Mail Address: ________________________

 

Mail Diploma To (if different from above):

Address:  _________________________________________________________
City:  _______________     State: ____             Zip:  _______    

For office use only, Do not write below this line.

Verified at the Registrar's office by________________________

---------------------------------------------------------------------------------------------------------------------------------
To: Donna Grzyb, Office of Provost
From : ___________________________________    Date: ____ / ____ / ____

 

Please order a diploma for the above graduate.                 Date diploma mailed:  ____ / ____ / ____