4525 Education Park Drive | Schnecksville, PA 18078
Phone: 610-799-1171 | Fax: 610-799-1173
APPLICATION FOR REPLACEMENT DIPLOMA
Use Black or Blue Ink ONLY
Please complete the application including signature.
Replacement diploma will be mail approximately 6-8 weeks after application has been received and processed.
For more information, please contact the Office of Registration/Student Records at registrar@mymail.lccc.
edu
or call 610-799-1171.
Cost for a replacement diploma is $40.00 payable to LCCC.
CLEARLY PRINT NAME TO APPEAR ON REPLACEMENT DIPLOMA
First Name Middle Name Maiden Name (optional) Last Name
Month of Graduation: August December May
Year of Graduation:
Degree Earned: Associate in Arts Certificate
Associate in Applied Science Specialized Diploma
Associate in Science
Program of Study:
Current Address:
Phone Number:
LCCC ID #: L SSN: DOB:
Date Signature
Date
ordered Diploma received Date mailed
OFFICE USE ONLY
Date received
PERM33B-u (8/20/15)
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