Please print clearly in black or blue ink.
Current Name:__________________________________________________________________
First Middle Last
Current mailing address:___________________________________________________________
___________________________________________________________
Current telephone number: (_____) ______-_______ Number of copies you are requesting: ____
Name at time of graduation: _______________________________________________________
First Middle Last
Student ID number:__________________ Original graduation date:______________________
(may use SSN) Month Year
Degree Earned:__________________________________________________________________
Business Office Use Only
Diploma Replacement Form
Instructions: Student, please complete form and
submit to the PVCC Cashier’s Office along with the
required fee ($10.00 per replacement). Diplomas
replaced as a result of a PVCC error are not subject
to a fee.
Once payment has been received, this form will be
forwarded to the Office of the Registrar and the
replacement diploma will be added to the order for
the current semester. Once received, your diploma
will be mailed to the address provided on this form.
Office of the Registrar Use Only
Degree Verified: _____ _____ Diploma Ordered _____ _____ Diploma Mailed _____ _____
By signing this request for a replacement diploma you are assuring that, to the best of your
knowledge, all information provided on this form is accurate. You also agree to pay the $10.00 fee per
each replacement ordered—no fee required if PVCC made the error—and the fee is payable by cash
or check only. Please remit this form and all payments to the PVCC Cashier’s Office during business
hours or mail to:
PVCC Cashier
501 College Drive
Charlottesville, VA 22902
Signature:_______________________________________ Date:____________________
Rev. 03/19 Student Services
