Rev. 7/25/18
REQUEST FOR DIPLOMA REPLACEMENT
A graduate of the Medical College of Wisconsin may request a replacement diploma if the original is damaged, destroyed, lost or
stolen, or if the graduate changes his/her name in which case the graduate must also complete the Request for Name Change form
and submit the original diploma to the Office of the Registrar. The replacement fee for a diploma is $100.00 (checks are payable to
the Medical College of Wisconsin). A replacement diploma is marked “Replacement” and sent via certified mail within six to eight
weeks of receipt of the request.
Name:
(Last name while enrolled at MCW) (First name) (Middle name)
Street:
City: State: Zip Code:
Phone: Email address:
Graduation Date(s): __________________________ Program(s) of Study: ___________________________________
Reason for Replacement Diploma: _____________________________________________________________________
Signature (required): ________________________________________ Date: __________________________________
_________________________________________________________________________________________________
The signature of a notary is required:
Subscribed and sworn to before me this ________ day of ______________________________________, ____________.
City/County of _____________________________, State of ________________________________________________.
Signature of Notary Public: _______________________________________________ Date: _____________________.
Commission Expires: _______________________
Return this signed form to:
Medical College of Wisconsin
Office of the Registrar, M3200
8701 Watertown Plank Road
Milwaukee, WI 53226
(414) 955-8733
acadreg@mcw.edu
