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Reissued Certificate Form

Please print, sign, and return the completed form to:

Academic Records
112 Shields Building
University Park, PA 16802-1271

Fax: 814-863-1929

Please print, sign, and return the completed form to:
Academic Records
112 Shields Building
University Park, PA 16802-1271
Fax: 814-863-1929

Identification

Please enter your name.
Please enter your former name.
9-digit Penn State ID number
Please enter your PSU ID.
*Only enter your SSN if you do not provide your PSU ID number.

Academic Information

Please enter your date of graduation.
Please enter your degree received.
Please enter the name of your certificate program.

Address Where Certificate is to Be Mailed

Please enter your name.
Please enter street address.
Please enter city.
Please enter zip code.
Please enter the country.
Please include area code
Please enter your daytime phone number.
Please enter a valid email address.

Reissued Certificate for Fall 2016 and Forward Fee ($25 for Each Certificate):

Please enter the number of certificate copies needed.
Multiply the number requested by $25 to calculate the total amount due
Please enter the amount due.

Payment

Please choose a payment method.


Please review your entries on this form. If all information is entered correctly, please print, sign, and submit the form to the address at the top.

Student Signature

Student Signature: _________________________________

Date: ______________________

Student Signature: _______________________________________ Date: __________________________

*The requested certificate will be mailed approximately two weeks after receipt of the request.
**Any request received that does not have payment enclosed or credit card information listed, will be returned to the sender.
**Returned checks due to insufficient funds will result in a service charge of $25.00.

Last Revised: 4/11/19