400 UMSU University Centre
Winnipeg MB R3T 2N2 Canada
Tel: 204-474-9420
Fax: 204-269-1065
Notice Regarding Collection, Use, and Disclosure of Personal Information by the University
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 purpose of determining your eligibility for Minnesota Reciprocity Status and to update
your University of Manitoba records accordingly. 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 Oce (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.
Under the Manitoba Minnesota Reciprocity Agreement, students who are residents of the state of Minnesota
as dened by the University of Manitoba, are granted reciprocity fee status.
After a successful application, a Minnesota Reciprocity Student pays the same tuition rate as a Canadian
Citizen. Please note, International Health Insurance fees will still be assessed. You must be admitted to
the U of M to submit this application. Incomplete applications will be destroyed. Minnesota Reciprocity
applications must be resubmitted annually to the Registrar’s Oce, prior to the start of classes.
APPLICANT INFORMATION:
Application for
MINNESOTA RECIPROCITY STATUS
Student Number:
Faculty:
Last Name(s):
Given Name(s):
Middle Name(s): Previous Name(s) (if applicable):
Phone Number: Date of Birth:
U of M Email:
SUPPLEMENTAL DOCUMENTATION CHECKLIST:
I have attached proof of my most recent Minnesota tax return
I have attached my parent or guardian’s most recent Minnesota tax
return where I am listed as a dependent
AND I have attached one of the following documents:
A copy of my Minnesota Driver’s License
A copy of my Minnesota Voter Registration
Copies of both sides of my Student Visa
A copy of my Minnesota Identication Card
A copy of my military dependent ID
*Please ensure that attached documents are legible.
DECLARATION:
I certify that the information given is true, correct, and complete to the best of my knowledge.
I understand that the falsication of information may result in disciplinary action.
Signature of Applicant
Date
OR
click to sign
signature
click to edit
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