UC Clermont - Reverse Transfer Form

First Name:

Last Name:

Email:

M-Number:

Type Selection You will automatically receive your UC Clermont associate degree. If you do not want to receive this degree, check here.

By checking this box, I decline my UC Clermont associate degree.

Group Selection Do you want a diploma?

Yes

Diploma Name

Type your name EXACTLY as it should appear on the diploma.

Re-enter diploma name

Diploma names MUST match in order to submit.

Have my diploma mailed to:

City:

State:

Zip Code