Consent Form - University Of Manitoba

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Registrar’s Office
400 University Centre
Winnipeg, Manitoba
Canada R3T 2N2
Tel: (204) 474-9420
Fax: (204) 269-1065
CONSENT TO
RELEASE OF APPLICANT’S UNDERGRADUATE / GRADUATE INFORMATION
I, _________________________________ Student Number______________________
(PLEASE PRINT)
Hereby authorize and consent to the release of any and all information contained in, or
a part of, my University of Manitoba student record to the following:
Name __________________________ Relation / Organization Title ________________
Name __________________________ Relation / Organization Title ________________
Name __________________________ Relation / Organization Title ________________
With the following exception(s) (i.e.: fees, grades, summer registration, etc.)
________________________________________________________________________
________________________________________________________________________
Signature: ___________________________________
Date: ___________________
THIS CONSENT WILL REMAIN IN EFFECT FOR 12 MONTHS
FROM ABOVE DATE

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