31 College Drive, Concord, New Hampshire 03301
TEL: 603-230-4014 FAX: 603-230-9314 nhtiregistrar@ccsnh.edu
REPLACEMENT DIPLOMA/CERTIFICATE REQUEST FORM
(Check which name you want printed on your replacement document)
Current Name:
Name on original diploma/certificate:
TEL: DOB
Year Graduated:
ID# or last 4 digits of SSN#
Degree Awarded:
Street
City, State, Zip
Signature:
Date:
PAYMENT OPTIONS
A
$20.00 processing fee must accompany this form (for diploma and professional certificate replacements only)
Cash
Credit Card:
Check (Make checks payable to: NHTI-Concord’s Community College)
Maste
rcard Visa Discover
Name on card (if different from above)
Account #
Exp. Date:
CV Code:
Billing Address
Street
City
State
Zip
Signature:
PLEASE NOTE THE FOLLOWING POLICY:
If someone other th
an you will be picking up your diploma/certificate from our office, they must bring written
authorization from you, as well as a picture ID, to be able to pick up your diploma/certificate.
Mail Diploma/Certificate to:
PTK Member?
Yes
No
Jostens Order Date:
JDiploma Mailed Date::
click to sign
signature
click to edit
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click to sign
signature
click to edit
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