APPLICATION FOR THE ISSUE OF A REPLACEMENT CERTIFICATE

Replacement Certificate:
1. / The University will not issue a replacement certificate to any applicant holding the original.
2. / Where a certificate is lost, damaged or accidentally defaced, a replacement certificate may be issued at the discretion of the University.
3.
4.
5. / The applicant MUST provide the University with EITHER the damaged or defaced certificate, OR, complete SECTION B of the Declaration fully.
Replacement Certificates will only be issued on receipt of completed form in hard copy (faxes and scanned forms will not be accepted).
If your award was conferred in 1992 (1993 for HND/C) please contact Student Records Unit before submitting this form
/ Please tick / Cost (£)
1.  University of Wolverhampton REPLACEMENT CERTIFICATE.
£35.00 (includes UK Special Delivery or airmail post in a hard backed envelope) / □
OVERSEAS POSTAGE
Airmail (in hard backed envelope) no cost
Airsure/International Signed For (in hard backed envelope) £20.00
WE WILL CONTACT YOU, EITHER BY PHONE OR EMAIL, WHEN WE ARE READY
TO TAKE PAYMENT / □
□
TOTAL
*IMPORTANT*
Applications will NOT be processed without proof of identity. Please provide:
1. Photocopy of recent utility bill showing name and address AND
2. Photocopy of relevant pages from your current passport and/or driving licence (paper section)
(If current name differs from student name you must provide documentary evidence e.g marriage licence, deed poll)
SECTION A (to be completed by ALL applicants in BLOCK CAPITALS)
Student name in full: / ______/ Date of birth: / ______
Full Award & Course Title: / ______/ Student ID No. / ______
Year of Award: / ______/ Associated Institution(If applicable) / ______
Home Address: / ______
Postal Address: (if different) / ______
______
Contact Details:
Telephone Number: / ______/ Email address: / ______
(FOR OFFICE USE ONLY)
Date received: / ______
……………………………….. / Amount of Fee: / ______
…………………………………………….
Duplicate certificate number: / ______
……………………………….. / Authorised: / ______
………………………………………………
Debtor status checked: / ______
……………………………….. / ______
………………………………………………
ID checked: / ______
……………………………….. / Date Despatched / ______
………………………………………………


REPLACEMENT CERTIFICATE

SECTION B Declaration to be completed by applicant if original certificate has been lost, explaining reasons for, and circumstances of, loss
enter full current name: / I,
explain full nature of loss/non-receipt / do solemnly and sincerely declare that
and I make the declaration conscientiously believing the same to be true and by virtue of the provisions of the "Statutory Declaration Act, 1835". I undertake that if a certificate is issued to me and I retrieve the original document, I will immediately return the replacement to the Student Records Unit, The University of Wolverhampton.
Applicant's Signature: / Date:
______
To be countersigned by: / Member of Parliament, Justice of the Peace, Minister of Religion, Doctor, Practising Solicitor, Teacher, Bank or Police Officer known to you for two years. (This may not be completed by a relative).
enter full name: / I,
certify that the applicant has been known to me for more than two years
enter in what capacity:
And that to the best of my knowledge and belief the facts stated on this form are correct
Witness’s Signature: / Date:
enter profession:
enter business name and address:
enter telephone number:

Please return form to:

Student Records Unit

University of Wolverhampton

MX Building

Camp Street

Wolverhampton

WV1 1AD

UK

Tel: 01902 323202 Email:

The University of Wolverhampton will process the data given to provide a replacement certificate, the information may also be retained for monitoring and statistical purposes.

rel_cert_let_conf.doc