TEXAS HIGH SCHOOL
DIPLOMA REQUEST FORM

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Name (Current Name): Date:
Address: Date of Birth:
City: State: Zip Code:
Phone Number: Cell Phone Number:
Name (at the time of attendance):
E-Mail Address:
Graduation Date: Pick-up    Mail
  • Payments must in the form of a Cashier Check or Money Order made payable to Texas High School.
  • Payments must be received along with this request form before the order can be processed.
  • By signing this request form, you acknowledge the $40 charge for each diploma and agree to make payment in full before each diploma can be ordered.
  • For mail in request: Must send a copy of your driver's license.
Mail Request Orders:
Texas High School
ATTN: Terri Gooden
4001 Summerhill Road
Texarkana, Texas 75503
For Office Use Only
Payment Received Date: ________________________ Amount: $40.00
Payment method: Cashier Check #:_______________ Money Order #:_____________________
Fund Request #:_______________________________ Purchased Order #:__________________
Ordered:_____________________________________ Received:__________________________
Received by:
Signature:____________________________________
 
Date:_____________________________
Date Mailed:__________________________________
*NOTE: ___________________________________________________________________