Request For Duplicate Or Replacement Diploma Form Page 2
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1
2Statutory Declaration
Justification for Replacement Diploma
Please print.
I, _______________________________________________________________________________________________________________________
of the City of _____________________________________________________ in the Province of _________________________________________
do solemnly declare
1.
That my true and legal name is as shown above.
2.
That my name on University of Waterloo records was as shown above or was
________________________________________________________________________________________________________________
3.
That I am unable to return the diploma originally issued to me by the University of Waterloo because it has been lost, damaged, or
destroyed.
4.
That I make this declaration for the purpose of identifying myself to the University of Waterloo and to qualify for the issuance of a
replacement diploma certifying my status as having graduated with the degree of
________________________________________________________________________________________________________________
Year (for example, 2013) ___________ Academic Group (Faculty) __________________________________________________________
5.
Sign the form in the presence of a Commissioner of Oaths.
Reset
Commissioner of Oaths
(please read)
A Commissioner of Oaths has the power to administer oaths required by legislation or regulation. In addition to a person authorized by the
Minister of Justice to act as a commissioner of oaths, the following, by virtue of the person's status, may receive oaths: court clerk and deputy
clerk; lawyer; notary; mayor, clerk, and secretary-treasurer in all municipalities, but only within the limits of the person's municipality; the
Secretary General, associate secretary general, and associate secretary of the National Assembly; justice of the peace.
Commissioner Contact Information:
Declared before me at the City of ____________________________
_________________________________________________________
in the Province of _________________________________________
Name (please print)
this _________ day of _____________________________________
_________________________________________________________
Telephone number (including area code)
20 ___________.
Please affix stamp or seal below.
_________________________________________________________
Commissioner of Oaths
_________________________________________________________
Declarant
Note: Declarant must sign this form before a Commissioner of Oaths.
Page 2
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