Name___________________________________________________________________________
Date______________________
Last First MI
Name as it appeared on the Original diploma______________________________________________________________________
Date Of Birth___________________ Student ID#__________________________ Telephone #______________________________
Current Mailing Address_________________________________________________________________________________________
PLEASE LIST Degree to be replaced
_______________________________________________________________________________
Mail Diploma to address below:
Paid:
_________________
_____________________________________________
____________________________________________
_________________________________________________
____________________________________________
Student Signature
Submit completed request forms to your campus’ Business Office or to the Registrar’s office or mail to:
Registrar’s Office 280 University Drive Beaver WV 25813. Or fax to 304-929-6719
If you any questions please contact Tonya Webb, 304-929-6722 or twebb@newriver.edu
You may phone the Business office, to make payment electronically
Mercer/Beckley- (304) 929-5448
¤
Greenbrier- (304) 647-6569
¤
Nicholas- (304) 883-2422
Replacement Diploma Request Form
(There is a fee for a Replacement Diploma, please contact the Business office for
current fee information.)
Street Address City State Zip
Replacement Diplomas can be picked up by student only (at the
Registrar’s Office in Beaver, WV) or mailed.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
