Course Certificate and Transcript Request Form

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					                                                                                                                                     Course Certificate and
                                                                                                                                   Transcript Request Form
Please complete and fax or mail this form to:
Mail: 625 René-Lévesque Blvd.West, 4th floor, Montreal, Quebec, Canada H3B 1R2                                                             Fax: 514.878.4260 or 1.866.535.1872 (toll-free)
For further information, please contact us by: Telephone: 416.364.9130 or 1.866.866.2601 (toll-free)                                                                           Email: customer_support@csi.ca



     Course Certificate                         Transcript Request Form Please indicate your request by ticking the appropriate box. Requests must be submitted in writing.

PERSONAL INFORMATION (All fields must be completed in CAPITAL letters to process registration)

CSI student number                                                                S.I.N. (last three digits only)
Applicant’s name                       Mr.           Mrs.           Ms.          Dr.      Language for correspondence                                   English        French
First name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Last name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Middle initial . . . . . . . . . . . . . .
Course certificate required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam date (MM/YY) . . . . . . . . . . . . . .

SHIPPING / MAILING ADDRESS                                                Business             Home
• Please provide a valid address where CSI correspondence and your course materials can be received and signed for during normal business hours (9:00 a.m. to 5:00 p.m.).
• Textbooks are shipped by courier and a signature from you or a person authorized by you will be required.
• Additional shipping and handling charges will apply if CSI has to re-ship course materials because of incorrect shipping instructions or if your order cannot be
  delivered because of an inability to obtain an authorized signature.
• CSI IS NOT ABLE TO REDIRECT YOUR COURSE MATERIAL AFTER YOUR ENROLLMENT APPLICATION HAS BEEN RECEIVED.

ADDRESS / CONTACT INFORMATION
Company name (if applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Apt. / Suite #. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Province. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postal code . . . . . . . . . . . . . . . . . Country. . . . . . . . . . . . . . . . . . . . . . . . . . .
Tel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Email address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Your email address is required to give you access to online courses, learning aids and the infocus Membership Program.)

Company name                    Past           Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tel. . . . . . . . . . . . . . . . . . . . . . . . . . .

LETTER OF AUTHORIZATION FOR TRANSCRIPT
Please accept this as your authorization for the release of all my academic results from CSI to:
Employer (name). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self / Student (name). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
And / or third party (name) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Student signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . .

For transcript, fill out the reverse side of this form. Number of transcript copies required. . . . . . . . . Fax transcript to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Course Completion Certificate Fee: $50 per certificate (+ applicable tax)
     NB, NS and NL residents: HST                           Quebec Residents: GST + QST                         Residents in all other provinces: GST
Transcript Fee: $35 (+ GST/HST)
     NB, NS and NL residents: HST                          Quebec residents: GST + QST                        Residents in all other provinces: GST
(GST/HST R869314518) (QST 1200091783)

PAYMENT INFORMATION
Fees are payable in Canadian funds. Money orders, cheques,Visa, MasterCard and AMEX are acceptable. A $40 charge will be applied to all NSF cheques. NSF cheques
must be replaced by a money order, certified cheque or credit card payment. Make cheques and money orders payable to CSI Global Education Inc.
IMPORTANT: Applications / Forms received without payment information, proper payment or with postdated cheques will not be processed.
Payment by Cheque or Money Order:                                              Personal cheque                   Firm cheque                 Money order           in the amount of $. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . is enclosed
Payment by Credit Card:                                Visa          MasterCard                 AMEX           Card number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expiry date (MM/YY). . . . . . . . . . . .
Name of card holder (please print) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Card holder’s signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
     Check here if you are faxing this form. You may be double charged if you fax this form and also mail the original to us.

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TRANSCRIPT REQUEST

Student name (include middle and/or maiden name) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please complete the following for each of the courses you want included on your transcript.                                                                                      Please allow 10–15 business days for processing.


Course                                                                                                                                                      Date Completed                                 Grade
(The period in which each course was offered is listed in brackets)                                                                                         (Please indicate the year
                                                                                                                                                             you completed your course)

Agricultural Markets – Risk Management Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                             ................................               .......................

Branch Managers Course (BMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    ................................               .......................

Branch Managers Exam (1987 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        ................................               .......................

Canadian Commodity Supervisors Exam (1980 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                     ................................               .......................

Canadian Commodity Futures Exam (1980–1985) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                 ................................               .......................

Canadian Funds Course (Quebec Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         ................................               .......................

Canadian Futures Exam (1985–1998) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     ................................               .......................

Canadian Investment Finance (Part 1) (1971–1992) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              ................................               .......................

Canadian Investment Finance (Part 2) (1971–1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              ................................               .......................

Canadian Investment Management (Part 1) (1992–1996) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                   ................................               .......................

Canadian Investment Management (Part 2) (1993–1999) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                   ................................               .......................

Canadian Operations Course (1989 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            ................................               .......................

Canadian Options Course (1975–1998) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         ................................               .......................

    Puts and Calls (1978) Calls (1975) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                ................................               .......................

Canadian Securities Course (1965 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         ................................               .......................

Conduct and Practices Handbook (July 1993 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                 ................................               .......................

Continuing Education Compliance Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          ................................               .......................

Derivatives Fundamentals Course (1997 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              ................................               .......................

FCSI (1976 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         ................................               .......................

Futures Licensing Course (1998 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                       ................................               .......................

Investment Management Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    ................................               .......................

IDA 1 (1950–1965). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          ................................               .......................

IDA 11 (1959–1965) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          ................................               .......................

New Entrants Course (1996 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                       ................................               .......................

Options Licensing Course (1998 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         ................................               .......................

Options Supervisors Course (OPSC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                      ................................               .......................

Partners, Directors and Senior Officers (1972 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               ................................               .......................

PHLX Currency Options (1982). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   ................................               .......................

Portfolio Management Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   ................................               .......................

Professional Financial Planning Course (1996 – present). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              ................................               .......................

Registered Options Principal (1975 – present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         ................................               .......................

Registered Representative Manual Exam (1971–1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                 ................................               .......................

Technical Analysis Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           ................................               .......................

Trader Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   ................................               .......................

Wealth Management Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  ................................               .......................

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