DUPLICATE DIPLOMA ORDER FORM 
Fee:  $15

NOTE:  Duplicate Diplomas will be available approximately 1-2 weeks after the order is received.

Name:             ____________________________________________________________ 
                    

Campus ID #:    ____________________________________________________________ 

Birth Date:        ____________________________________________________________               

Name as you wish
it to appear
on your diploma:_____________________________________________________________ 
                        (please print)  

Mailing Address
for diploma:        _____________________________________________________________

                        _____________________________________________________________

                        _____________________________________________________________
 

Degree Received: _____________________________________________________________ 

Year Received:    _____________________________________________________________  

Contact
Information:        _____________________________________________________________
                                (in case we have any questions)

Signature:          _____________________________________________________________

Please print and complete this form. Mail it to the address below along with your payment. Make a $15 check payable to UW-La Crosse.

Mail to:    UW-La Crosse
              Records and Registration
              ATTN:  Victoria Rahn
              117 Graff Main Hall
              1725 State Street
              La Crosse, WI  54601