COLLEGE OF SAN MATEO Office of Admissions and Records 1700 West Hillsdale Blvd., Sa Mateo, CA 94402–3784 n
Tel: (650) 574‐ 6165 Fax: (650) 574‐ 6506
Duplicate Request for A.A/ A.S Degree and Certificate
Print Name: _________________________________________ Student ID: G#/ SSI No:___________________ Address where diploma should be mailed: _______________________________________________________ No. Street __________________________________________________________________________________________
City State Zip
Telephone Number: ____________________________ E‐Mail: _____________________________________ Year Attended CSM: ________________ Year Awarded CSM: ______________________________ CSM Major: _____________________________________ Option: _______________________________ Student Signature: ____________________________________ Date: ____________________________________ Payment Authorization: Submit payment of $10.00 per diploma. Number of copies to be sent to the address: _____________________________________________________ Please Check: American Express Discover Master Visa Credit Card Number: _________________________________ Expiration Date: _________________________ Card V‐ Code (Required) ____________ (it is the last three (3) digits located on the black of your credit card on the signature line.)
Amount to be charged: $ ____________ for Fall Spring Summer 20____ (Year) I here by authorize the above amount to be billed to my credit card for the above named student. __________________________________________ Print Name of Cardholder ___________________________________________ ______________________________ Signature of Cardholder Date OFFICE USE ONLY Date Received: _______________________________ Initials: ___________________________________
MNS A&R May 7 , 2008.
th