Credential Request Form
222 St. Patrick Street Toronto, ON M5T 1V4
email@example.com │ 1 (416) 596-3117 or 1 (800) 387-9066
Credential Request Form 1 5/21/2020
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.
PREVIOUS NAMES (while attending Michener)
(_________) __________ - _______ _
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).
Mailing Charges – Please allow 4 to 6 weeks after graduation
[ ] Canada (10.00) [ ] U.S (25.00) [ ] International (50.00)
(in person only)
(personal cheques are not accepted)
Cardholder Name (Please Print)
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.
OFFICE USE ONLY:
Processed by: ____________________________________________________________________