!
!
!
!!1101!Sherman!Drive,!Utica,!NY!13501!
!!!!!!!!!!!!!!!!Phone!(315)!792=5336!
!!!!!!!!!!!!!!!!!!Fax!(315)!792=5698!
!!!!!!!!!!!!!!!!!!!!!!www.mvcc.edu!
!
Name ___________________________________________________________________________
Last First MI
Previous Name ____________________________ Date Of Birth ____________________________
Phone Number ____________________________ Email __________________________________
Degree Awarded ___________________________ Date Awarded ___________________________
Mailing Address ___________________________________________________________________
Street City State Zip
There is a $25 processing fee for a copy of your diploma. Please submit this form along with payment of check
or money order made payable to: Mohawk Valley Community College. If you prefer to pay by credit card,
please call the Business Office at (315) 792-5475 to pay by phone and submit this form to the Office of
Records and Registration.
________________________________________________________________________________
Signature Date
!
Received!By/Date !____________________!
Paid!____________________!
Date !P rinted/I nitials!____________________!
Date !Mai led/Initials!____________________!