Updated November 2020
Replacement Diploma Request
Student ID or SSN: Phone:
Name: Date of Birth:
Previous Name(s):
Street: City: State: Zip:
Replacement Diploma for (degree/certificate)
Replacement Diploma for (degree/certificate)
Delivery Method:
☐ I will pick up my replacement diploma within one month or I understand it will be destroyed.
☐ I authorize a third party to pick up my replacement diploma. Photo ID of authorized party required.*
Third Party:
☐ Mail my replacement diploma to the address indicated below.
Student Signature: Date:
(Proof of identification must be provided at time of submission. If mailing include copy of valid photo ID.)
*When authorizing a third party to pick up replacement diploma(s), third party valid ID is required. A copy of the student’s valid ID containing
student’s signature must be provided.
Mail form and required documents to Student Records Office, One College Drive, Bentonville, AR 72712
Turn in at Enrollment Support Center located on the 2
nd
floor of the Student Center or at the Washington County Center (if available)
Upload to https://api.nwacc.edu/lss/finaid/filedropbox/
(must have myNWACC login)
Processed by: ________
Date: _______________
Scanned by: _________
Date: _______________
I understand that checking this box constitutes a legal signature
