Replacement Diploma Request Form - White Mountains Community College

Reorder Replacement Diploma Form

Complete ALL information below. Please allow 4-6 weeks for mail delivery.

Name(Required)

First Last

Student ID #

Please complete all information below(Required)

NAME ON ORIGINAL DIPLOMA

DEGREE/CERTIFICATE AWARDED

YEAR GRADUATED

Please choose your method of payment for the $20 Processing Fee

Check (make payable to White Mountains Community College)

Credit Card

In order to process this request, the $20 fee must be paid in advance. Payment can be made by check or credit card. Please call the Welcome Center 603-752-1113 to make payment over the phone.

Please Mail Diploma To:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Please provide the best contact number.

Email(Required)

Signature(Required)

Date