Fillable LIST ANY OTHER NAMES YOU MAY HAVE USED (College of the Redwoods)

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LIST ANY OTHER NAMES YOU MAY HAVE USED (College of the Redwoods)

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Full Name _______________________________________________ Date of Birth ________________________
Phone _____________________________________ Email ________________________________________
LIST ANY OTHER NAMES YOU MAY HAVE USED WHILE ATTENDING CR
Previous First Name: _____________________________ Previous Last Name: ___________________________
NOTE: If you have legally changed your name since you last attended CR, your Diploma/Certificate will appear
with the name we have on file. If you would like to update your name with CR so your Diploma/Certificate will
reflect your current legal name, you should first submit the Student Information Update Form, along with your valid,
government-issued photo ID and your updated Social Security Card, to the Admissions and Records Office.
DIPLOMA/CERTIFICATE REPRINT INFORMATION
Name to Appear on Diploma/Certificate: ___________________________________________________________
Program to Appear on Diploma/Certificate: _________________________________________________________
*If you have completed multiple programs, you must complete a separate form for each Diploma/Certificate reprint request.*
Awarded: ___________________________ ___________________________
Year Semester
Number of copies requested: _____________ Cost per copy: _____________ Total due: _____________
Mailing Address for Diploma/Certificate: ___________________________________________________________
Street Address
______________________________, _____________, ______________
City State Zip Code
GRADUATE’S ACKNOWLEDGEMENT
By signing below, I acknowledge understanding that the replacement Diploma/Certificate will bear the
signatures of the current state and College officials.
Graduate’s Signature: ________________________________________ Date: _________________________
If you have any questions, please email evaluator@redwoods.edu
or call (707) 476 – 4205.
DIPLOMA/CERTIFICATE
REPRINT REQUEST
SUBMISSIONS BY MAIL
Make US Bank check or Money Order out to
: College of the Redwoods
In the memo, write
: Diploma/Certificate Reprint
Mail
this form along with check/Money Order to:
College
of the Redwoods
Admissions & Records Office
7351 Tompkins Hill Rd
Eureka, CA 95501
SUBMISSIONS IN PERSON
Submit full payment to
: Cashier’s Window
Submit this form & receipt to: Enrollment Services Window
1
$ 20.00
$ 20.00
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LIST ANY OTHER NAMES YOU MAY HAVE USED (College of the Redwoods)

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Completed 2 February 2021

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