400 UMSU University Centre
Winnipeg MB R3T 2N2 Canada
Tel: 204-474-9420
Fax: 204-269-1065
Required Information:
Name of Applicant: __________________________________________________________________
Relationship to Deceased: _____________________________________________________________
Address: __________________________________________________________________________
_________________________________________Postal Code: ______________________
Daytime telephone number: ___________________________________________________________
Name of Deceased: __________________________________________________________________
Student Number (if known): ___________________________________________________________
Tax Year(s) Requested: ________________________________________________________________
Delivery Method (check one):
Pick up myself* Courier**
(cannot courier to a PO BOX)
Pick up by a person I authorize*: Additional courier fees will apply:
$20.00 Anywhere in Canada
(first and last name of person authorizes to collect the document) $50.00 Anywhere in U.S.A
Mail or Fax** $100.00 International/Overseas
* Photo ID will be required upon pick up.
**Please complete the Delivery Information section, below.
Delivery Information:
Recipient Name: ___________________________________________________________________________
Address or Fax: ____________________________________________________________________________
Note: Items cannot be couriered to a PO BOX number.
City and Province/State: ________________________________ Postal/Zip Code: ______________________
Signature:______________________________________________ Date:_______________
Notice Regarding Collection, Use, and Disclosure of Personal Information by the University
This 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 completing your request for a Student History. 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.
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