Release of Applicant's Info Consent Form
Enrolment Services
CONSENT TO RELEASE OF APPLICANT’S
UNDERGRADUATE / GRADUATE INFORMATION
I, ___________________________________________ Student Number: _________________
(PLEASE PRINT)
Hereby authorize and consent to the release of any and all information contained in, or part of,
my University of Manitoba student record to the following:
Name: _______________________________________________________________________
Relation / Organization Title: _____________________________________________________
Name: _______________________________________________________________________
Relation / Organization Title: _____________________________________________________
Name: _______________________________________________________________________
Relation / Organization Title: _____________________________________________________
With the following stipulated exception(s) (i.e., fees, grades, summer registration, etc.):
Signature: ______________________________________ Date: _________________________
THIS CONSENT WILL REMAIN IN EFFECT FOR 12 MONTHS FROM THE ABOVE DATE
Notice Regarding Collection, Use, and Disclosure of Personal Information by the University
Your personal information is being collected under the authority of The University of Manitoba Act. The information you provide
will be used by the University for the purpose of obtaining your consent for the exchange of your personal information between
the specified individuals or University offices. Your personal information will not be used or disclosed for other purposes, unless
permitted by The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection
of your personal information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University
of Manitoba, Winnipeg, MB, R3T 2N2.
Financial Aid & Awards
422 University Centre
Winnipeg, Manitoba
Canada R3T2N2
Telephone (204) 474-9531
Fax (204) 474-7543
awards@umanitoba.ca
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