School of Nursing transcript request - Health Sciences Centre

Name*

Surname Given Name(s)

Surname at Time of Graduation*

Current Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Email Address*

Daytime Phone

TRANSCRIPT INFORMATION

Transcript(s) / Verification(s) requested*

Program

Year Graduated (yyyy)

Transcript sent to (Address)

Transcript sent to (Email)

Please select program for which transcript / verification is requested and indicate the year graduated.

Be Sure to indicate if you wish more than one copy of your transcript sent (i.e. x 2 copies sent to an address).

NOTE: “Official Transcripts” can NOT be sent to you. If you require a copy sent to more than two institutions, please indicate this on this form and send a secondary page.

TRANSCRIPT / VERIFICATION FEES

Sent within Canada

Price:

Quantity

Sent outside of Canada

Price:

Quantity

Replacement Diploma

Price:

Quantity

TOTAL AMOUNT OWED

PAYMENT

NOTE: Cash is not an option

Type of Payment

Cheque

Credit Card

Total Amount Owed

Please make your cheque / money order payable to the Health Sciences Centre and send it to:.

Transcripts, HSC Winnipeg,
NA138-820 Sherbrook Street,
Winnipeg, MB, R3A 1R9

NOTE: If your account is not in Canada, you must send a money order or certified cheque in Canadian funds.

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Credit Card info

Which Credit Card?

AMEX

MasterCard

VISA

Card Number

Security Code

Expiry Date (dd-mm-yyyy)

Name as it appears on your Card

Name

This field is for validation purposes and should be left unchanged.