Name in which your credential was/is to be awarded in:
(Please type or print) ___________________________________________________________
*Must be the legal name of record or be comprised from the legal name of record at the time the credential was
awarded. (Example: Mary Ann Smith or Mary A. Smith or Mary Smith).
*Suffix such as Jr., Sr., II, III, cannot be added if they were not part of your permanent name of record at the time
your credential was awarded.
Student ID: __________________________ SSN: _____________________ DOB: __/__/____
DIPLOMAS: CERTIFICATES:
__TD: Technical Diploma __TCA: Technical Competency Area
__AALT: Associate of Arts Louisiana Transfer __CGS: Certificate of General Studies
__AAS: Associate of Applied Science __CTC: Career and Technical Certificate
__AGS: Associate of General Studies __CTS: Certificate of Technical Studies
__AS: Associate of Science
__ASLT: Associate of Science Louisiana Transfer
__ASN: Associate of Science in Nursing
Campus that awarded the credential:
__Bastrop __Jonesboro
__Lake Providence __Monroe
__Ruston __Tallulah
__West Monroe __Winnsboro
Semester/Year the credential was awarded: Spring _____ Summer _____ Fall_____ (Ex: Spring 2014)
Mailing Address: *(NO P.O. Boxes – Must be a physical address for UPS delivery)
Street Name and Number:
_______________________________________________________________
City, State, Zip Code:
___________________________________________________________________
Daytime Phone Number:
________________________________________________________________
Personal E-mail Address:
________________________________________________________________
Signature (required):
_________________________________________
Date:
_________________
Payment can be made in person at the Bursar’s Office at the Monroe campus or at the Cashier’s Office on
any community campus.
The cost for each copy/additional copy of a credential is $15.00 (per each copy ordered).
Payment method:
_____ Check or money order enclosed
_____ Please assess fee(s) and I will contact the Bursar’s Office at 318-345-9133 with payment
information.
Submit completed form along with payment (check or money order payable to LDCC):
Louisiana Delta Community College
Registrar’s Office ATTENTION: Sydney Gregory
7500 Millhaven Rd
Monroe, LA 71203
FAX Number: 318-345-9002
For additional information, please contact Sydney Gregory 318-345-9191
LOUISIANA DELTA COMMUNITY COLLEGE
Academic Affairs ◦ Office of the Registrar
Request for Official Certificate or Diploma
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signature
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