UPPER GRAND DISTRICT SCHOOL BOARD 500 VICTORIA ROAD NORTH, GUELPH, ONTARIO, N1E 6K2 PHONE: (519) 822-4420 FAX: (519) 826-9534 Martha Rogers, Director of Education REQUEST FOR ONTARIO STUDENT TRANSCRIPT AND OTHER STUDENT RECORDS TYPE OF RECORD REQUESTED: Ontario Student Transcript Proof of Age Proof of Attendance Verification of Education Other: Please specify: PROCEDURE: 1. 2. 3. Complete this form and deliver it (in person or by mail) to the last school you attended, together with two pieces of identification e.g. Birth Certificate, Driver’s License, Passport. (Photocopies are acceptable.) Enclose a cheque or money order for the total amount due, payable to the school. Payment MUST be received before the request is processed. Should you wish to have someone pick up your Record(s), you must provide a letter of permission naming the person and sign the letter. The person authorized to pick up the record will be asked to produce identification. PERSONAL INFORMATION: (Please print or enter electronically) Surname First Name Number Initial Street Maiden Name City Name of School Last attended in Upper Grand District School Board (formerly Wellington or Dufferin Counties) Final Year Province Postal Code Telephone Number D.O.B. (yyyy/mm/dd) COST: NOTE: Present students are not charged for Transcripts or other records. Charges apply to students retired for one year or more. Past students or employers will be charged at the rate below, inclusive of regular postage. Any costs incurred for premium shipping (courier, express post, etc.) will be the responsibility of the applicant. Total number of copies required: X $5.00 for each copy DELIVERY INSTRUCTIONS: Address above Pick Up = Total Amount Due Send record(s) to: Prospective Employer: Name OUAC number Name of University OUAC number Name of University OUAC number Name of University OCAS number Name of College Other: Particulars: Signature of Applicant or Designate: Date: (yyyy/mm/dd) FOR SCHOOL USE ONLY 9 Identification Received Signature of School Staff: 9 Transcript Picked Up 9 Transcript Mailed Date: (y/m/d) The authorization for the collection of this information is in the Education Act and Ontario Student Record Guidelines. The purpose is to receive proof of identification for the release of school records. The school’s Administrative Staff will be the primary users of this information. Contact person for queries is the School Principal. Revised 2010/03 Ad-*opted 1994/04