400 UMSU University Centre
Winnipeg MB R3T 2N2 Canada
Tel: 204-474-9420
Fax: 204-269-1065
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 updating your personal records with your new legal name or designated
gender. 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 Oce (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.
LEGAL NAME AND/OR GENDER DESIGNATION CHANGE
Student Number: Date of Birth: Phone Number:
The current spelling of your name as it appears in your University of Manitoba records (you can see this on your Aurora account).
First Name(s) Middle Name(s) Last Name(s)
Your full legal name as it should now appear in your University of Manitoba records (this must match your name as it appears on your supporting
documentation). Please print clearly using upper and lower case letters. If applicable, clearly indicate all diacritical marks such as accents, umlauts,
or any other special characters.
First Name(s) Middle Name(s) Last Name(s)
If your name has been legally changed please provide:
Government issued Change of Name Certicate
OR
Government issued marriage certicate and birth certicate and a government issued ID (ex. driver’s license) showing your current full
name.
OR
Government issued divorce decree and birth certicate and a government issued ID (ex. driver’s license) showing your current full name.
If your name needs to be CORRECTED in your University of Manitoba records (spelling error, adding or deleting a name) please provide
one of the following:
Birth Certicate
OR
Government issued Change of Name Certicate
OR
Government issued study permit and passport (for international students only)
OR
Immigration documentation or citizenship paper or permanent resident card.
I understand that if my personal identication does not match the name I wish to place on my UM records, it is my responsibility to prove
that I am the individual who belongs to this name.
I understand that my request will not be processed in the event that there is illegible, incomplete, or missing documentation.
Signature: Date:
If you have changed your designated gender:
Male Non-binary (Transgender, Transsexual, Two-spirited and Intersex)
Female
STUDENT DECLARATION AND SIGNATURE:
click to sign
signature
click to edit
Notied: Yes
Date:
Initials:
OFFICE USE ONLY:
Screen Updates:
Current Faculty/School/College:
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