Please complete your full name below as you wish it to appear on your replacement diploma:
First name Last name used while in attendance
Social Security Number or Banner ID Daytime Phone #
Degree Type (circle diploma requested) BA BFA BPS BS BSN MA MFA MPA MS MS in Ed MSW CAS
Date of Birth Date of Degree Major/Graduate Program
month day year month year
Mailing Address - Please send diploma to:
street address city state zip
The College at Brockport
State University of New York
Office of Registration and Records
Students who have lost or damaged their College at Brockport diplomas may request a replacement diploma for $15.00.
Please complete this form and return it with your payment to the Office of Registration and Records (address below). We will
process your request within 7-10 business days.
/ /
Student’s Signature date
Please mail, email, or fax the replacement diploma form to:
The Office of Registration and Records
The College at Brockport
350 New Campus Drive
Brockport, NY 14420-2966
Fax: (585) 395-5392
Phone: (585) 395-2531
Replacement diplomas are $15.00 each. Payment may be made by cash, check, or money order only. Please indicate below.
Cash payments are accepted in person ONLY. Credit card payments are NO LONGER accepted.
[ ] Payment by check $ enclosed (Please make check payable to SUNY Brockport).
[ ] Payment by money order $ enclosed.
[ ] I will be bringing in a cash payment.
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