Request for
Replacement Diploma
Allow ten business days for processing.
No request will be processed without payment.
Mail completed, signed form and a $25 check or money order (payable to NGTC) to the following address:
North Georgia Technical College
Attention: Office of the Registrar
PO Box 65
Clarkesville, GA 30523
Type or Print Legibly
Student ID # or last 4 digits of Social Security #:
Phone:
( )
Email Address:
Name as you wish it to appear on diploma:
Name under which you attended NGTC (if different):
Mailing Address:
State:
Zip Code:
Program of Study:
Student Signature:
Date:
(Required)
For Office Use Only
Paid:
/
Mailed
/
Picked Up:
/
Hold:
Non-Payment
Other Financial Obligation
(Date)
(Initial)
(Date)
(Initial)
(Date)
(Initial)
As set forth in the student catalog, North Georgia Technical College does not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age,
political affiliation or belief, genetic information, disabled veteran, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law). For
complaints or information, contact Mike King, VP of Student Affairs (706- 754-7711, Title VI, IX, II), or Kay Morgan, special services contact (706-754-7828, Sec. 504/Title I/ADA) at
1500 HWY 197 N, Clarkesville, GA 30523.
This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter
containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. 9/14/16
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