Registrar’s Office
115 South St
Middletown, NY 10940
Telephone: 845-341-4140
Fax: 845-342-8662
Duplicate Diploma Order Form
Please print this order form and fill out below. Mail/Fax the completed order form with payment to address
above. The fee for a duplicate diploma is $20.00. The fee can be paid by cash (in person only), check or
certified money order payable to “SUNY Orange”, VISA, Master Card or Discover Card. Please allow six to
eight weeks for processing.
Please note: Your name will appear on your duplicate diploma exactly as it appeared on your original. The
replacement diploma will state “Duplicate.”
DO NOT WRITE BELOW THIS LINE * FOR OFFICE USE ONLY*
Date Received:
Bursar Fee Paid____________________
Initials ___________________________
Date _____________________________
Check for Holds ______________________
Degree Awarded ______________________
Graduation Date _____________________
Initials_________________________
Notes:
Date Ordered_________________
Initials_______________________
Notes:
Sent for Signatures:
Date: __________ Initials: ___________
Initials__________________________
Notes:
Date Mailed: _____________________
Initials ___________________________
Tracking:
Name:
DateofBirth Maiden(Former)Name:
CurrentMailingAddress:
StudentID#:A
(OR)
SSNID#:
City/State/Zip
EmailAddress: TelephoneNumber:
GraduationDate:
Signature(REQUIRED): Date:
Ifpayingbycreditcardpleaseincludethefollowing:
VISAMasterDiscoverCard
NameonCard:______________________________________________
CreditCardNumber:__________________________________________
ExpirationDate:_____________SecurityCodeNumber:_____________
*Billinginformation
(Onlyifdifferentfrommailingaddress
above)
Address
City/State/Zip
