Diploma and Certificate Reprint Request

*Date:

*SSN/Student ID:

*Full Name When Attending UA-PTC:

*Date of Birth:

*Did you attend UA-PTC before 1991?

*Graduation year:

*Degree(s) earned:

*Name you wish to be printed on your diploma:

*Street Address:

*City, State and Zip:

*Phone:

*E-mail:

If your contact information (including e-mail, address, phone number) on file is different from this form, do you agree for the Office of Records to update your information?

*Choose one method of delivery. One request form per mailing address is required.

If you selected Mail, please enter the mailing address below.

Note: If the mailing address is the same as above, type in the space: same address provided

If you selected pick up and would like to allow your document(s) to be picked up, please provide the individuals name:

Note: A valid photo ID must be presented by anyone picking up document(s). Documents not picked up within two weeks will be mailed to the address provided on this form.

*Student Signature:

I understand that typing my full name in this box constitutes a legal signature.