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

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

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Credential Request 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 Request Form 1 5/21/2020
Date Received
Office Use Only
Credentials must be requested by the student within one year of Graduation.
PERSONAL INFORMATION [ ] Tick this box if you would like to update the address on file with the address below.
SURNAME OF GRADUATE
PREVIOUS NAMES (while attending Michener)
FIRST NAME
MIDDLE NAME
STUDENT ID #
PROGRAM NAME
GRADUATION YEAR
ADDRESS
CITY OR TOWN
PROV.
POSTAL CODE
TELEPHONE
(_________) __________ - _______ _
EMAIL ADDRESS
PICK UP OR MAILING INSTRUCTIONS:
Signature required upon receipt of Credential
Photo ID required
2020 Credentials Available after June 15, 2020.
If someone else is picking up a credential on your behalf, please write
their name here (they will be required to show ID).
Name: ______
Mailing Charges – Please allow 4 to 6 weeks after graduation
for Shipping.
[ ] Canada (10.00) [ ] U.S (25.00) [ ] International (50.00)
Cash
(in person only)
Debit Card
(in person only)
Money Order
Certified Cheque
(personal cheques are not accepted)
Credit Card
Visa
AMEX
MasterCard
Cardholder Signature
Cardholder Name (Please Print)
Date
EXPIRY DATE
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: ____________________________________________________________________
Date: ____________________
PAYMENT METHOD
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Credential Request Form (The Michener Institute of Education at UHN)

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Completed 10 February 2021

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