Last Name: ______________________________ First Name: ________________________ Middle Initial: __________
Date of Birth: _________________ Email: _________________________________ Phone: ______________________
Mailing Address: __________________________________________________________________________________
City: __________________________________________ State: _______________ Zip Code: _____________________
Degree or Certificate Program: ______________________________________ Graduation Date: _________________
Name as you want it to appear on your diploma:
_________________________________________________________________________________________________
(PLEASE PRINT CLEARLY)
Signature: ______________________________________________________ Date: ____________________________
Cape Cod Community College graduates are able to request replacement diplomas in cases of loss, damage, or name
change for a minimal fee of $20.00. In order for your diploma to be processed, CCCC will need to verify your student
information provided below. The Registrar’s Office does not maintain copies of your diploma. If you need immediate
proof of your degree, the Registrar’s Office can provide an official academic transcript per paid written request.
• In accordance with FERPA, only the individual who earned the diploma can request a replacement.
• The replacement diploma will be issued with the signatures of current school officials.
• Completed forms can be mailed, faxed, or scanned and emailed to the Office of the Registrar.
• Please allow 4-6 weeks for mailing of your diploma.
Request for name change:
If your name has changed since graduation and you would like the name change to be used for the replacement
diploma and changed in your student records, you will need to submit a Change of Biographical Data form with legal
proof as required. For security and legal purposes, a legal document such as a marriage license, divorce decree,
adoption papers, certificate of name change at naturalization, or other court order indicating change of name must be
presented or attached.
Credit Card/Payment Information (MC, Visa and Discover only):
Credit Card Number: __________________________________ Exp Date: ________ CCV #: ______
Card Holders Name: _______________________________________________________________
Best Phone Number for Contact: ______________________________ Amount: _______________
Billing Address: __________________________________________ST ____ Zip Code ___________
Card Holder’s Signature Required: ____________________________________________________
Check #: ________________________ Money Order: _______________
Date Received: ______________ Date Processed: ______________
Office of the Registrar – REPLACEMENT DIPLOMA ORDER FORM
2240 Iyannough Road │ West Barnstable, MA 02668
774.330.4711 │ Fax: 508.375.4084 │ registration@capecod.edu │ www.capecod.edu
