Duplicate Degree Request Form

Mail request to: Merced College
Attn: Evaluator, Box 14
3600 M Street
Merced, CA 95348-2806

Or Fax with Credit Card information to: (209) 384-6339

The name on your degree or certificate will be re-issued as it originally appeared

Please print legibly.

Last:______________________ First:____________________ Middle:_________________

Street Address: __________________________________________________________

City: _______________________ State: ______________ Zip: ___________

Phone Number: ___________________________

Year of Graduation:____________________ Major: ___________________________

Social Security Number: ________________________

Date of Birth: __________________

Please send $10.00 check or money order made out to Merced College; or to charge to a credit card, list Visa or Master Card number:

Credit Card Number: _____________________________ Expiration Date: ___________

_________________________________ Date: ____________
Signature (For all Requests)

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