Student Registration Form Subject Code: Course Number: Course Title: CRN: Course Fee: (C$) Student Information: * indicated required field Have you ever Registered at University of Manitoba?* ---YesNo What is your 9 digit student number (if known): Eg. (005555556) First Name:* Middle Name: Preferred First Name: Last Name:* Date of Birth (yyyy-mm-dd):* Citizenship:* ---CanadianPermanent ResidentOther Country:* Home Address:* City:* Province/State:* Country:* Postal Code/Zip:* Email Address:* Day Telephone: (10 digits required) * I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in automatic withdrawal from the course and/or program. Your personal information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purposes of registration, communication, and to facilitate payment. Your personal information will not be used or disclosed for other purposes, unless permitted by The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2. Important Notice “Submit” will direct you to a secure, external payment site in a new window and will close automatically after a successful payment is processed.