Updated 12/11/18
Request for Duplicate Diploma or Certificate
*Indicates required field
Full Name* ______________________________________________________________________________
Student ID/SSN* _______________________________________ Date of Birth* _______________________
Street City State Zip
Phone* _______________________________ Email* ____________________________________________
Indicate which degree or certificate you are requesting*:
Associate of Arts __________________________________________ Date earned _______________
Associate of Science _______________________________________ Date earned _______________
Associate of General Studies ________________________________ Date earned _______________
Associate of Applied Science ________________________________ Date earned _______________
Certificate of Completion ____________________________________ Date earned _______________
Duplicate diplomas/certificates will be mailed to the address listed above and will be issued to the name
provided above.
Student’s Signature* ___________________________________________ Date _______________________
Return completed form to:
Mailing Address: Clackamas Community College, Graduation Services,
19600 Molalla Ave, Oregon City, OR 97045
Location: Graduation Services, Community Center Room 121
Email: gradservices@clackamas.edu
For questions, contact:
Phone: 503-594-6651
Email: gradservices@clackamas.edu
Date Mailed:
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