METHOD OF PAYMENT
I request MCC to reprint my (please check only one):
Payment Information (please check only one):
Check # __________________________________
Because (please check only one):
Original was lost or damaged
First Name MI Last Name
City State Zip
Home Phone Number Cell Phone Number Work Phone Number
Student Signature Date
Signature of Cardholder Date Signed
Address of Cardholder (if different from above)
Name of Program
Credit Card Number
Please indicate method of payment below. Make checks payable to MCC.
FOR REGISTRAR OFFICE USE ONLY
Veriﬁed By ______________________________________________________ Date _____/______/_______
Reorder By ____________________________________________________ Date _____/______/_______ Date Mailed _____/______/_______
Please complete this form (one form for each diploma/certificate), sign, date and submit with a $20.00 fee for each diploma/certificate request to: Manchester
Community College, Bursar’s Office, MS #10, Great Path, P.O. Box 1046, Manchester, CT 06045-1046. Make checks payable to MCC. Please allow 5-6 weeks for
delivery after verification by the Registrar’s Office.
Note: Diploma or certiﬁcate will reﬂect the same name as the original award.
Banner ID Number