400 UMSU University Centre
Winnipeg MB R3T 2N2
Canada
Fax: 204-269-1065
Phone: 204-474-6018
REQUEST FOR REPLACEMENT PARCHMENT(S)
*NOTE: The Replacement Parchment looks similar to the original, and the wording certifies that you graduated, but IT IS NOT A
DUPLICATE OF YOUR ORIGINAL PARCHMENT. The fee for a Replacement Parchment is $75.00. Cheques/Money Orders should be
made payable to the University of Manitoba. You may also pay by credit card (if ordering by mail or fax, please fill out credit card
information on reverse). If ordering in person you may also pay by debit.
Allow approximately five working days from our receipt of this request for processing.
Current Name: _________________________ _________________________________ Student Number: ___________________
Last Name(s) Given Names
Date of birth: ____________________________ Daytime telephone number: _______________________________
Reason for request: Original parchment has been lost/stolen/destroyed/damaged (complete Sections A and C)
Name has changed since graduation (complete Sections B and C)
(Please note that all parchments you received from the U of M in a previous name must be
replaced at the same time)
Both of the above (complete Sections A, B and C)
Section A
I, _________________________________________________________, Student # __ ____ ____ ______ __ __ ____ ____,
do hereby certify that the original parchment(s) for my______________________________________________________
(Specify the name of degree/diploma/certificate you received)
issued to me when I graduated in_______________________________________________________________________
(Month and Year)
was/were LOST: STOLEN: or DESTROYED/DAMAGED:
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 records to reflect your full legal name and to replace your parchment(s). 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.
Proceed to back of this page to complete your request
FOR OFFICE USE ONLY
Date Ordered: Date Shipped/Set for Pick Up:
Section B
This application must be accompanied by:
1. Completed Request for Change of Name form and ALL required documents (if Change of Name not already processed)
2. Original parchment(s)
Degree/Diploma/Certificate
to be replaced
Date of graduation
Name as it appears on original parchment
Section C
Additional Courier fees: (cannot courier to a PO box)
FOR PICK UP: MAIL OUT: PLEASE COURIER: *$20.00 Anywhere in Winnipeg
*$50.00 Anywhere in Canada or U.S.A
*$100.00 International/Overseas
Shipping address (mail or courier only):
Name:_____________________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City/Province: _________________________________________________________________ Postal Code: ____________________________
Signature: ____________________________________________________ Date: ____________________________
Payment: Cheque/Money Order: MasterCard:* Visa:* *No other cards accepted.
Card #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiry Date: __ __ / __ __
(Month) (Year)
I hereby authorize payment of $____________ using the above noted credit card and number.
Total amount
Card holder signature: __________________________________________ Date: ____________________________
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