Replacement Diploma Request
Note – Replacement diplomas are issued with the titles and college officials who were present during the
graduation term. Please allow 2-3 weeks for delivery.
Current Name (Please Print) ___________________________________________________________________
Previous Name ______________________________________________________________________________
Student ID Number __________________________________________________________________________
Date of Birth _______/___________/__________
Mailing Address ______________________________________________________________________________
Phone Number (______)____________________________
Email Address _______________________________________________________________________________
Print your name below exactly as you want it to appear on the diploma.
(If this section is not completed, the legal name in our records will be used)
First Name _____________________________ Middle _________________ Last _____________________________
Degree Awarded ____________________________________________________________________________
Month/Year Degree Conferred ________________________________________________________________
Honors Received ____________________________________________________________________________
(Note: Phi Theta Kappa, Latin Honors, etc.)
Qty: ______ Diploma (at $10 per copy) _____ Diploma Cover (at $10 per cover)
Student Signature Date
Mail this form and payment (if applicable) to: Washington State Community College – Records Office, 710 Colegate Drive,
Marietta, Ohio 45750; via email to email@example.com; or faxed to 740-568-1965.
Payment can be made by check, money order, or by credit card. If you wish to use a credit card, please contact the Business
Office at 740-568-1905 to make the payment via the telephone.
Office Use Only: Request Completed by ____________________ Date _____________________
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