Request for Duplicate Diploma Form

MISSISSIPPI VALLEY STATE UNIVERSITY
OFFICE OF STUDENT RECORDS
MVSU 7264
14000 HWY 82 WEST
Itta Bena, MS 38941-1400

To request a duplicate diploma, please complete the information requested below and remit payment of $20.00 made payable to Mississippi Valley State University. The duplicate diploma will bear the original name as it appeared on your original diploma, and carry the original titles and signatures of the University and Board of Trustees officials.

Please send the $20.00 payment of the cost of the duplicate diploma (includes standard shipping charges) to the address listed above. Payment is accepted via a money order or cashier’s check. Cash payment is acceptable only if paying in person.

The fields marked with * are required.

Name as it originally appeared on your diploma *

Date Requested

Your Major

Degree Awarded (B.A., B.S., M.A., M.S., etc.) *

Graduation Date (Month, Year) *

Daytime Telephone # *

Alternate #

Email *

Please send duplicate diploma to:

Name

Mailing Address

City

State

Zip Code

Signature:

Confirmation Receipt Number *

You agree that by typing your name, you are electronically signing this document.

I agree

Date

Leave this field blank

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Request for Duplicate Diploma Form

MISSISSIPPI VALLEY STATE UNIVERSITY OFFICE OF STUDENT RECORDS MVSU 7264 14000 HWY 82 WEST Itta Bena, MS 38941-1400

MISSISSIPPI VALLEY STATE UNIVERSITY
OFFICE OF STUDENT RECORDS
MVSU 7264
14000 HWY 82 WEST
Itta Bena, MS 38941-1400