Request for Replacement
Certificate / Degree
You may request a replacement award only if you have previously
applied and received a certificate or degree.
Please pay $10.00 processing fee at Cashier.
S
TUDENT’S NAME
(PLEASE PRINT)
LAST ___________________________________________________________
FIRST ___________________________________________________________
MIDDLE ___________________________________________________________
NAME USED WHILE ATTENDING _______________________________________
STUDENT ID NUMBER OR SOCIAL
SECURITY NUMBER USED WHILE ATTENDING __________________________
DATES OF ATTENDANCE _____________________________________________
CURRENT MAILING ADDRESS _______________________________________
_____________________________________________
_____________________________________________
PHONE NUMBER _____________________________________________
Please choose one:
HOLD FOR PICK UP (Held for 30 days then destroyed)
MAIL TO ADDRESS ABOVE
STUDENT’S SIGNATURE _____________________________________________
TODAY’S DATE _____________________________
PLEASE ALLOW 5-8 BUSINESS DAYS FOR PROCESSING
---------------------------------------------------- OFFICE USE ----------------------------------------------------
Processed By: _____________________________________________________________
Date Mailed: ______________________________________________________________
Hold For Pick-Up Contact Dates: ______________ ______________ ______________
Enrollment Services Office
Tel: 253-589-5666 Fax 253-589-5852
4500 Steilacoom Blvd SW
Lakewood WA 98499
click to sign
signature
click to edit
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