Replacement Award Certificate Request Form
The cost of a replacement award certificate is $100. Please return this form along with payment to: Finance, Wintec, Private Bag 3036, Waikato Mail Centre, Hamilton 3240
Student ID Number: First Names: Last/Family Name: Mailing Address Number/Street: Suburb: City: Telephone: Award (Qualification gained): Year Award Completed: Post Code: Mobile:
Statutory Declaration (to be completed by student in front of a Justice of the Peace) I, _____________________________ solemnly and sincerely declare that the certificate previously issued to me has been destroyed in the following circumstances: Student’s signature
I request a new certificate and make this solemn declaration conscientiously believing the same to be true by virtue of the Oaths and Declarations Act 1957
Declared at: Date: Justice of the Peace: (Or other person authorised to take a statutory declaration)
JP stamp here
CREDIT CARD PAYMENT
Card Number:
Visa/Mastercard (Select One)
(Amex/Diners NOT accepted)
Amount: $______________
Expiry Date: _____________
Name on Card: __________________________________________ Signature: ______________________________________________ Date: __________________________
SEIC - Academic Services Use Only First Ref no: Printed by: Date Printed: First Date of issue: Verified by: Finance manual receipt to student Date sent to student:
C:\Users\isklp\Desktop\Replacement Award Certificate Request Sep 09.doc