Duplicate Credential Request

This form is used to request a duplicate credential (i.e., certificate, diploma, degree). Please complete the information below as accurately as possible. Failure to supply requested information may result in your request being delayed. The credential will be mailed to the address you list below. Please use a separate form for each credential requested.

Fee Charged

There is a $20.00 fee per each credential requested.

Make money orders payable to JCTC. Paying with personal check will delay the processing by at least three weeks.

Mail or return this form (along with $20.00 fee) to:

Jefferson Community & Technical College
ATTN: Graduation
109 E. Broadway
Louisville, KY 40202

 

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Print your name EXACTLY the way you want it to appear on the credential (titles such as Mr., Mrs., etc. will not be used):

_______________________________________________________________________________________

Social Security # or Student ID #: ________________________

Telephone #: __________________________

Email address: ___________________________________________

Address Credential will be mailed to:

____________________________________________________

____________________________________________________

 

Credential Requested: ____ Certificate      ____ Diploma      ____ AA      ____ AS       ____ AAS

Area of concentration or major: __________________________________________________________

When was the credential awarded: Year ___________      Semester _________________

**Please note: Due to the use of an outside vendor, reprints of credentials may take up to 12 weeks from the date the form is submitted to the records office.

 

Office Use Only

Amount Paid: $______________      CASH _________      MO # ____________

Date Received: ________________ Received by: ______________________________