Fillable Credential Replacement Form (The Michener Institute of Education at UHN)

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Credential Replacement Form (The Michener Institute of Education at UHN)

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Credential Replacement Form
Registrar’s Office
222 St. Patrick Street Toronto, ON M5T 1V4
regoffice@michener.ca │ 1 (416) 596-3117 or 1 (800) 387-9066
Credential Replacement Form 1 4/1/2020
Date Received
Office Use Only
All information on this form must be correct and complete. Payment must accompany this request.
Credential replacements may take up to four (4) weeks for processing.
PERSONAL INFORMATION
LAST NAME (while attending Michener)
FIRST NAME
STUDENT ID #
DATE OF BIRTH (mm/dd/yyyy)
_______ /_______ /_________
PROGRAM NAME AND YEAR OF GRADUATION CREDENTIAL EARNED
PROGRAM
_____________________________________
YEAR
________________
[ ] Advanced Diploma [ ] Graduate Certificate
[ ] Continuing Education Certificate
CONTACT INFORMATION Tick this box if you would like to update the address on file with the address below.
ADDRESS
CITY OR TOWN
PROV.
POSTAL CODE
TELEPHONE
(_________) __________ - _______ _
EMAIL ADDRESS
PICK-UP [ ] Self ID Required MAIL-OUT [ ] Canada (10.00) [ ] U.S (25.00) [ ] International (50.00)
• Personal cheques and debit-credit are not accepted
• All certified cheques/money orders payable to:
The Michener Institute of Education at UHN
MAILING ADDRESS (if different from contact information above)
STREET
PROVINCE
PAYMENT METHOD
Advanced Diploma/Graduate Certificate $50.00 per copy Number of Copies:
________
Continuing Education Certificate $25.00 per copy Number of Copies:
________
Cash (in person only)
Credit Card (Visa, MC, AMEX)
M
oney Order (or Certified Cheque)
D
ebit (in person only)
Card #: ________________________________ Expiry Date: __________________
Enter Numbers Only – No Spaces MM/YY
Name: _________________________________ Signature: ___________________
PRINT CLEARLY
AUTHORIZATION AND DECLARATION
I certify that the information contained herein is true, correct, and complete. The information on this form is collected under the authority of the
Michener Institute of Education at UHN and will be protected and used in compliance with the Ontario Freedom of Information and Protection of
Privacy Act, R.S.O. 1990, c. F.31. Student information held by the Michener Institute of Education at UHN may be used for administrative and
statistical purposes of the Institute and/or the ministries and agencies of the Government of Ontario and the Government of Canada.
Student/Graduate Signature
: ______________________________________________
Date
_______________________
OFFICE USE ONLY:
Processed By
: _________________________________________________________________
Registrar’s Office
Date _____________________
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Credential Replacement Form (The Michener Institute of Education at UHN)

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Completed 10 February 2021

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