Replacement Certification Documentation Request Form

Replacement Certification Documentation Request Form
Section 1: Student Details
Full Name as enrolled
Student ID
Date of Birth

DayMonthYear
Date
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Postal Address
Section 2: Award Details
Award Title (e.g. Master of Information Technology and Innovation)
Course Code (if known)
Conferral Date (or approximate)

DayMonthYear
Date
Graduation Ceremony (if applicable)
Campus or Delivery Mode
Section 3: Document(s) Requested
What kind of Document do you require?
Section 4: Reason for Request
Why do you require replacement?
If other, please specify
Note: The Institute may require documentary evidence (e.g., statutory declaration, police report, damaged original).
Section 5: Declaration and Consent
I declare that the information provided in this form is true and correct to the best of my knowledge. I acknowledge that the reissued certification documentation will be marked as a replacement and that the Institute may verify my identity and request supporting documentation.
Date

DayMonthYear
Date
Signature
Section 6: Identification and Supporting Documents Checklist
Certified copy of photo identification passport or drivers licence
Original damaged certificate if applicable
Evidence to support reason for replacement eg police report statutory declaration
Proof of payment of replacement fee refer to the website for current charges
Section 7: Office Use Only
Received by
Date Received

DayMonthYear
Date
All documents provided
Identity verified
Payment confirmed
Approved by (Registrar/Delegate)
Date of Reissue

MonthDayYear
Date
Replacement documents sent on
Notes
Should be Empty:

Replacement Certification Documentation Request Form

Section 1: Student Details

Section 2: Award Details

Section 3: Document(s) Requested

Section 4: Reason for Request

Section 5: Declaration and Consent

Section 6: Identification and Supporting Documents Checklist

Section 7: Office Use Only