REQUEST FOR REPLACEMENT or DUPLICATE DIPLOMA
Student ID Number: W
Name
Last First Middle
Street _______________________________________________________ Apt/Unit # ___________________
City _________________________________ State _________________ Zip Code ___________________
Phone _________________________________ Email
Semester/Year of Completion:
Semester: SPRING SUMMER
FALL Year: 20_____
The major/certificate title is: ________________________________________________________________
Your diploma name will be printed as it appears on your permanent student record.
If you want a different name printed on your diploma, you must provide legal documentation of your name change
to the Admissions & Records Office
prior to this application
.
By signing below, I certify that my request is complete and accurate. I am responsible for knowing
the information provided.
STUDENT SIGNATURE
DATE
Submit this form to:
Mail to: Las Positas College, Of
fice of Admissions & Records, 3000 Campus Hill Drive, Livermore, CA 94551
Fax to : 925.606.6437
Honors:
Highest Honors:
________________________________________________________________________________
First
Middle
Last
Number of copies_______@ 20.00 each=$________
Check One:
Please mail my diploma to the address indicated above: (Add additional $10.00 mailing fee: )
Please hold my diploma for pick up (We will contact you when its ready)
Total Amount due: $__________
____________________________________________
___________
_______________________________________________________________________________
Business Office Use Only
PAID:________________________ By: ___________________________
* Please allow 4-6 weeks for Processing.
