UPPER GRAND DISTRICT SCHOOL BOARD
Version while schools are closed to the public 2020/09 (Fee Increase effective Sept. 1, 2019)
REQUEST FOR ONTARIO STUDENT TRANSCRIPT OR REPLACEMENT DIPLOMA
Ontario Student Transcript Replacement Diploma
PROCEDURE: This form may be submitted as an online form or printed and signed.
1.
Complete this form, certifying the personal information being provided (as an adult over 18,
or on behalf of a person as a guardian) with a signature or by checking the box below.
2.
Submit the form to the last school attended with amount due (payable to the school).
NOTE: Transcript requests made by a third party must include an “authorization to release
personal information” signed by the client/past student.
PERSONAL INFORMATION: (Please print or enter electronically)
__________________ ___________________ ____________________ __________________
Surname First Name Former Legal Name, if any Date of Birth (yyyy/mm/dd)
____________________________ ______________ ________________ (best time) __________
Name of Last School Attended Final Year Telephone number to contact for clarification
COST:
Note: Present students are not charged for transcripts. Charges apply to students retired for one year or
more. Past students or third party reps with consent will be charged at the rate below, inclusive of regular
postage to Canada and the United States. Costs incurred for premium shipping (courier, express post, etc.)
or to International addresses will be the responsibility of the applicant and will be arranged with the sender.
Number of Copies: ______ @ $20 first copy (+ $5 additional transcript) = $_______ Total Amount Due *
* Payment in the form of cash, cheque, money order or online debit/credit (options on school website)
is required before the request is processed. Multiples must be ordered at the same time.
DISTRIBUTION INFORMATION:
PICK UP (photo ID required)
OR MAIL to name and address below:
By applicant or By Other
Certification box below must be checked confirming ID
See note above for premium/International shipping charges.
If Other: I authorize release of record to:
________________________________________________
Full name _________________________
________________________________________________
__________________________________
Signature of above authorized individual
picking up the record (signed at pick up)
________________________________________________
If entering an email address, you agree to the risks involved.
CERTIFICATION OF INFORMATION for personal request for transcript:
By checking this box and/or signing below, I certify the information given to be true.
APPLICANT’S SIGNATURE: ___________________________ DATE: __________________
The authorization for the collection of this information is in the Education Act and Ontario Student Record
Guidelines. The purpose is to receive application for the release of school records. School Administrative
Staff will be the primary users of this information. Contact person for queries is the School Principal.
FOR SCHOOL USE ONLY
Transcript/Diploma Delivered Staff Signature: _________________________
Diploma request for paper made ________________
Date: __________________________
Pick up is not available since schools are closed to the public.
