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

Student Name

Please enter your name.

Former Name

Please enter your former name.

PSU ID 9-digit Penn State ID number

Please enter your PSU ID.

*SSN *Only enter your SSN if you do not provide your PSU ID number.

Academic Information

Date of Graduation

Please enter your date of graduation.

Degree Received

Please enter your degree received.

Certificate

Please enter the name of your certificate program.

Address Where Certificate is to Be Mailed

Name

Please enter your name.

Street Address 1

Please enter street address.

Street Address 2

City

Please enter city.

State

Zip Code

Please enter zip code.

Province

Country

Please enter the country.

Day Phone Number 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):

Number Requested

Please enter the number of certificate copies needed.

Total Amount Due Multiply the number requested by $25 to calculate the total amount due

Please enter the amount due.

Payment

Please choose a payment method.

Check (Enclosed, Payable to The Pennsylvania State University)

Credit Card (Visa, MasterCard, Discover or American Express)

Credit Card Number

Expiration Date

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