Office of the Registrar
505 Ramapo Valley Road, Mahwah, NJ 07430-1680
Phone (201) 684-7695 Fax (201) 684-7956
New Jersey’s Public Liberal Arts College
P:\Shared\Registrar\Forms\Replacement Diploma\Replacement Diploma reorder form.doc 07.30.19
Request for Replacement Diploma
If you are requesting a replacement diploma based on a name change, you must fill out a name
change request with the Registrar's Office in addition to this form.
Student I.D. Number (or SS# prior to Fall 06):
Student Name as it is t
o appear on diploma:
First name Middle Name Last Name
If a name change, please indicate the name that was on the original diploma:
First name Middle Name Last Name
Reason for request of replacement diploma:
Current Email Address: ____________________________________________________
Mail diploma to:
I understand that the repl
acement diploma will clearly indicate that it is a replacement/duplicate
diploma and that the signatures will represent the college officials, at the time of reprint. The cost
of the replacement diploma is $30.00 and it will take approximately 6 weeks for it to be received.
Signature Date
Office Use Only
Date Rec'd Fee Rec'd _________ Diploma Ordered _________
er Checked__________________ Grad Term____________
Major ____________ Honors ____________ Balance ______________ Holds____________
click to sign
click to edit