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DIPLOMA REQUEST FORM:

1. PLEASE NOTE: PLEASE PRINT OR TYPE VERY CLEARLY AND EXACTLY AS YOU WOULD LIKE YOUR INFORMATION PRINTED ON YOUR DIPLOMA.

2. Name to Appear on Diploma: ___________________________________________________

3. Address to Send Diploma to: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. PLEASE NOTE: Make Check or Money Order for $ 150.00 in Canadian Dollars, to TRAFALGAR DISTANCE LEARNING INSTITUTE. Please use the form below to make your payment by Visa or Master Card.

5. For Credit Card Payments Please Print your information here:

Credit Card Type: ___________________________________
Credit Card Number: _________________________________
Exact Name on CC: __________________________________

Three or Four Digit Pin On Back of Card: ________________
Signature: __________________________________________
Date: ______________________________________________

You may also phone in your Credit Card Information to us!!
1 403 347 9019, 1 888 686 6163, or 1 403 454 2887.

Student Services Officer Signature: ___________________________________________________

Presidents Signature and Date: ___________________________________________________

___________________________________________________

END OF DIPLOMA REQUEST ORDER FORM.