CC A&R 5/7/15 JN
11600 Columbia College Drive
Sonora CA 95370
209.588.5232
☐ Evaluator Confirmed Award
Date Mailed ________ Date Ready for Pickup _________
Comments ______________________________________
OFFICE USE ONLY
DUPLICATE DIPLOMA/
CERTIFICATE REQUEST
Please complete and submit the following information to Admissions and Records in person or by US mail with payment or
payment information. Please do not send cash through US mail. A replacement fee is required at time of request; $15.00
for a diploma and $10.00 for a certificate. Duplicates are only printed at the end of each semester. Requests cannot be
processed without payment.
_________________________________________________________________
First Middle Last
Student ID# __________________________ Date of Birth ______________________
Phone _____________________________ Email ___________________________
Type of Degree (AA/AS/ASOE/AAT/AST; SAC/CERT) _______________________________
Major _______________________________________ Grad Date _______________
Student Signature ___________________________________ Date ______________
Choose one option: Pick Up (photo ID required) Mail (provide address below)
*ADD $5.00*
____________________________________________________________________________
(Street/PO Box)
____________________________________________________________________________
(City) (State) (Zip)
Check Money Order/ Cash VISA/MasterCard
Cashier’s Check Discover
I, as a current or former student of Columbia College, by my signature authorize the Admissions and Records
Office to process this request. I understand fees are required at the time of request with all financial obligations
being satisfied prior to processing. Should I choose to provide payment by credit card, I will take full
responsibility for fees should the card be declined.
____________________________________________________________________________
Signature Authorizing Charge to Credit Card Below Date
___________________ __________________________________________________________
Name (as it appears on card) Billing Address City State Zip
Receipt #______________ Authorized Amount: $______________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Remove information below and destroy after payment is processed - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Credit Card Number: _ _ _ _-_ _ _ _- _ _ _ _-_ _ _ _ Exp Date (MM/YY): _ _ _ _ CVC Code: _ _ _
Payment Method:
*Name will be printed EXACTLY as it appeared on your original Diploma/Certificate*
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signature
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