Diploma Re-issue Request Form 졸업장 재발급 신청서

Student Information (학생 정보)

Full Name(신청자 이름)
Name on Diploma (졸업장에 들어갈 이름)	* Legal Name at the Time of Graduation
Date of Birth (생년월일)	Student ID (학생 ID)
Phone No.(전화번호)	Email (이메일)

Program Information (학위 정보)

Program/Degree (학위과정)
Graduation Year (졸업년도)

Reason for Re-issue (재발급 사유)

☐ Lost ☐ Damaged ☐ Misspelled Name ☐ Other: ________________

Fee & Delivery Information (재발급 비용과 발송 정보)

Mailing Address (발송 주소)
Delivery Method (발송 방법)	☐ Standard ☐ Express ☐ Pick-up
Reissue Fee (재발급비)	$30
Shipping Fee (발송비)	☐ Standard/$10 ☐ Express/$25
Total (합계)	$

Student Signature ( 서명 )__________________________________________ Date (날짜) _______________________________

Office use only

Approved	Student Dean’s Signature	Date
Processed by	Registrar	Date
Payment Received	☐ Yes ☐ No	Finance Office