The University of Western Ontario OFFICIAL TRANSCRIPT REQUEST Office of the Registrar (internal processing time is 4-5 business

days) Telephone: (519) 661-2100 FAX: (519) 850-2397

Date: _______________________ PLEASE PRINT CLEARLY FULL NAME ______________________________________________________ First Middle Surname CURRENT ADDRESS _______________________________APT#___________ CITY __________________________________ PROV/STATE_______________ POSTAL/ZIP CODE _________________ COUNTRY _____________________ EMAIL ADDRESS __________________________________________________ DAY TIME PHONE NUMBER (__________) ____________-________________ INSTRUCTIONS Will pick up #________ copies (Photo I.D. Required) I understand that no one may pick up my transcript without a signed letter of consent from me plus their personal photo I.D. Transcripts must be picked up within 6 months of ordering. Student Number: |____|____|____|____|____|____|____|____|____|

S.I.N: (optional; for I.D. purposes only)_________ - __________ - _________ Date of Birth: _________/_________/_________ month day year

Previous Surnames (if applicable): ________________________________ Years Attended: from: ____________ to: ____________ Year Graduated (if applicable): _____________________ Failure to provide complete information may delay or prevent processing.

Student Authorization *I CERTIFY THAT I AM THE STUDENT AS STATED.

THE INFORMATION PROVIDED IS TRUE AND CORRECT IN ALL RESPECTS. I HEREBY AUTHORIZE THE UNIVERSITY OF WESTERN ONTARIO TO RELEASE TRANSCRIPTS AS INDICATED.

OR
Mail #_________copies (Full Mailing Address For Transcript(s) Is Required Below): (PLEASE PRINT CLEARLY) Name/Dept: ________________________________________________________ Institution/Company: _________________________________________________ Building/Room #:____________________________________________________ Address: ___________________________________________________________ City: __________________________________Prov/State: ___________________

X ________________________________________________ Signature *(legal signature is required) *Transcripts are protected under the Freedom of Information and Protection of Privacy Act

PROCESSING INSTRUCTIONS (check ONE only) Separate order forms must be completed for each of the options below. Do NOT hold for grades (internal processing time approximately 4-5 business days and does not include mailing time) Hold for Mid-Year grades (courses completed first term) Hold for Final (Fall/Winter) grades (statement of Degree Conferred will NOT appear) Hold for Summer grades (statement of Degree Conferred will NOT appear) Hold for Degree to be Conferred to appear June October Negative service indicators placed on academic records will prevent the release of transcripts. The University of Western Ontario is not responsible for transcripts lost or delayed in shipping.

Country: ______________________________Postal/Zip Code: _______________ Telephone #: (__________)____________________Buzzer Code______________ (required if courier service selected) (if applicable)

The above will be sent by regular mail unless the courier service option is checked in the box below. Additional fees apply for courier or fax services
Courier Service (NOT available to P.O. Box addresses. Street address is required) Fax to: # (______)_________________________________ Fax and destination address must be the same recipient. Official transcript must follow by mail or courier. Full mailing address for transcript must be provided in area designated above.

FEES - All fees payable at time of request and are subject to change.

TRANSCRIPTS $12.00 per copy

(includes the cost of regular mail)
____# of transcript(s) x $12 = add courier fee (if applicable) + add fax fee (if applicable) + Total Amount Payable = Courier: $15.00 within Ontario $25.00 remainder of Canada & USA $50.00 for International (additional charges may apply for return shipments) |____|____|____|____| |____|____|____|____| The following services are additional to the transcript fee and are nonrefundable: Fax transmissions: $12.00 per fax number. Official transcript must follow to recipient. (maximum of 3 attempts for unsuccessful transmissions)

Visa/MasterCard

Credit Card #: ____|____|____|____| |____|____|____|____|

Expiry Date: _____/_____

Cardholders Name as it appears on card _________________________________Cardholders Signature ___________________________

If paying by cheque/money order or cash/debit do not fax your order. Debit Card Cheque/Money Order Cash (do not mail cash)