Registrar’s Office
222 St. Patrick Street Toronto, ON M5T 1V4
regoffice@michener.ca │ 1 (416) 596-3117 or 1 (800) 387-9066
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.
General Payment Form 2020-04-08
Office Use Only
The Michener Institute of Education at UHN requires personal and contact information, payment details, and payment method transcribed on the following General
Payment Form in order to process any requested Registrar’s Office payment arrangements.
Note: Additional documentation such as receipts and/or financial information verification may be required. This application must be completed and signed in ink and all
questions must be answered.
NOT TO BE USED FOR: CE Registration, Credential Replacement, Invigilation, Official Transcript, Part-Time Application, or Confirmation of Enrolment.
PERSONAL INFORMATION
LAST NAME (while attending Michener)
STUDENT ID #
DATE OF BIRTH (mm/dd/yyyy)
_______ /_______ /_________
CONTACT INFORMATION
(____) ______ - _______
PAYMENT DETAILS
PAYMENT FOR _______________________________________ $___________.___
____________
___________________________ $___________.___
____
___________________________________ $___________.___
TOTAL PAYMENT $___________.___
PAYMENT METHOD
Cash (in person only)
Credit Card (Visa, MC, AMEX)
Money Order (or Certified Cheque)
Debit (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 and in the supporting documents is true, correct, and complete. I authorize the release of my personal information to
The Michener Institute of Education at UHN’s Registrar’s Office and Finance administration, for the purposes of the General Payment.
Student/Graduate Signature
: _____________________________________________
Date
______________________
OFFICE USE ONLY:
Processed By
: ________________________________________________________________
Registrar’s Office Staff Name
Date
_______________________
Tick
this box if you would like to update the address on file with the address below.
