Diploma or Certificate Replacement – River Valley Community College

Student ID # (if known)
Name*
First Middle Last
Name while attending (if different from above)
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Telephone #*
Last 4 #s of SSN*
DOB (optional)
Date Format: MM slash DD slash YYYY
Academic Program*
Year Graduated
- Associate Degree
- Certificate
- Diploma
Name exactly as you would like it to appear on your diploma:*
(Please print clearly. This is where you can decide if you want your middle name or initial, a formal first name or a shortened version, etc.)
Replacement Fees*
- Replacement Diploma ($20.00)
- Replacement Cover ($20.00)
Payment Options*
- I will send a check or money order, payable to “CCSNH.”
- I will make a credit card payment over the phone to the Business Office by calling 603-542-7744.
Delivery Options*
- Please mail diploma/cover
- Hold diploma/cover for pickup at RVCC in Claremont when ready. (If someone other than yourself will be picking up the diploma/cover, they must bring signed written approval from you.)
Signature*
Date*
Date Format: MM slash DD slash YYYY