Issuu on Google+

FORM NO. N QFAS00 043

R Replace ement / Third d Party Reque est STUDEN NT I.D: ______ ____________ _______

SCHOOL: __________ ___________ ____________ ______

............................................................................................................................................................................. Full Name (please print)

............................................................................................................................................................................. Address

.............................................................................. Ph: (Work)

Ph: (Ho ome) ..........................

Signature

............................................................................................................................................................................. Course No o.

C Course Title

ndicate below w (tick) the rep placement or rreprint you require: Please in

† Replaccement Acaademic Record FFEE APPLIC CABLE:

$$20

C CONDITIONS S: 1 1. If applyin ng for a re-priint Academicc Record in a new name, this request must be accompanied byy Form Q QFAS0014 S Student Amen ndment Details and docum mentary evid dence i.e. ma arriage certificcate or deed poll. 2 2. Fee is non n-refundable..

† Replaccement Cerrtificate or Diiploma FFEE APPLIC CABLE:

$$50 per Certificate or Dipploma

C CONDITIONS S: 1 1. Application ns must be a accompanied d by a correcttly completed d Statutory D Declaration (a an example iss overleaf). T The Stat. Decc. form is ava ailable from the Post Officce. 2 2. In the event of the orig ginal certificatte / diploma being b found, it will be retu urned immed diately to Gre eat Southern In nstitute of Te echnology. 3 3. Fee is non n-refundable.

FFEE APPLIC CABLE $55

† Certifieed Copy of AAcademic RRecord

SCHO OOL STUDE ENTS ONLY Y

† OOriginal Academic Recoord sent to school † CCertificate seent to schoool

SE ONLY OFFICE US

Fee Payyable: ............................................ R Receipt No. .................................................................. Receivin ng Officer........................................... Date ........................................................................ Date ................... Processed By ................................................................ Record Reprinted This doccument to b be filed on Student S File Great Soutthern Institute off Technology ©

01/09/2011

1 of 2


Example: Statutory Declaration I,

Joe Student

of

42 Fictitious Street, Albany WA do solemnly and sincerely

declare as follows:-

The original diploma awarded to me for Diploma of Visual Arts in September 1997, by the Great Southern Regional College has been lost. Joe Student 12/12/2008 And I make this solemn declaration conscientiously believing the same to be true and by virtue of Section 106 of the ΑThe Evidence Act 1906". DECLARED AT

Albany

in the State of Western Australia this

twelfth

Before me

December 1997

day of

Mr Justice of the Peace

Statutory Declaration forms are available from the Post Office QFAS0043 Replacement / Third Party Request

01/09/2011

2 of 2


Replacement certificate