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If you have any queries please contact the UNC Operations Department on: [email protected]<br /><br /></p> </div> </div> </li> <li id="cid_4" class="form-input-wide" data-type="control_head"> <div class="form-header-group "> <div class="header-text httal htvam"> <h2 id="header_4" class="form-header" data-component="header"> Student Details </h2> </div> </div> </li> <li class="form-line" data-type="control_number" id="id_6"> <label class="form-label form-label-top form-label-auto" id="label_6" for="input_6"> UNC Membership No </label> <div id="cid_6" class="form-input-wide"> <input type="number" id="input_6" name="q6_uncMembership" data-type="input-number" class=" form-number-input form-textbox" style="width:420px" size="50" value="" placeholder="ex: 23" data-numbermin="0" data-numbermax="100" data-component="number" aria-labelledby="label_6" /> </div> </li> <li class="form-line" data-type="control_datetime" id="id_7"> <label class="form-label form-label-top form-label-auto" id="label_7" for="lite_mode_7"> Date of Birth: </label> <div id="cid_7" class="form-input-wide"> <div data-wrapper-react="true"> <div style="display:none"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="month_7" name="q7_dateOf[month]" size="2" data-maxlength="2" value="" aria-labelledby="label_7 sublabel_7_month" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="month_7" id="sublabel_7_month" style="min-height:13px"> Month </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="day_7" name="q7_dateOf[day]" size="2" data-maxlength="2" value="" aria-labelledby="label_7 sublabel_7_day" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="day_7" id="sublabel_7_day" style="min-height:13px"> Day </label> </span> <span 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class="form-sub-label-container" style="vertical-align:top"> <label class="form-sub-label" for="input_7_pick" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap"> Date Picker Icon </label> </span> </div> </div> </li> <li class="form-line" data-type="control_fullname" id="id_5"> <label class="form-label form-label-top form-label-auto" id="label_5" for="prefix_5"> Name </label> <div id="cid_5" class="form-input-wide"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top"> <select data-component="prefix" name="q5_name[prefix]" id="prefix_5" class="dropdown-match-height form-dropdown" aria-labelledby="label_5 sublabel_5_prefix"> <option value="Mr."> Mr. </option> <option value="Mrs."> Mrs. </option> </select> <label class="form-sub-label" for="prefix_5" id="sublabel_5_prefix" style="min-height:13px"> Prefix </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="first_5" name="q5_name[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_5 sublabel_5_first" /> <label class="form-sub-label" for="first_5" id="sublabel_5_first" style="min-height:13px"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="last_5" name="q5_name[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_5 sublabel_5_last" /> <label class="form-sub-label" for="last_5" id="sublabel_5_last" style="min-height:13px"> Last Name </label> </span> </div> </div> </li> <li class="form-line" data-type="control_address" id="id_9"> <label class="form-label form-label-top form-label-auto" id="label_9" for="input_9_addr_line1"> Address </label> <div id="cid_9" class="form-input-wide"> <table summary="" class="form-address-table"> <tbody> <tr> <td colSpan="2"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_9_addr_line1" name="q9_address[addr_line1]" class="form-textbox form-address-line" autoComplete="address-line1" value="" data-component="address_line_1" aria-labelledby="label_9 sublabel_9_addr_line1" /> <label class="form-sub-label" for="input_9_addr_line1" id="sublabel_9_addr_line1" style="min-height:13px"> Street Address </label> </span> </td> </tr> <tr> <td colSpan="2"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_9_addr_line2" name="q9_address[addr_line2]" class="form-textbox form-address-line" autoComplete="address-line2" size="46" value="" data-component="address_line_2" aria-labelledby="label_9 sublabel_9_addr_line2" /> <label class="form-sub-label" for="input_9_addr_line2" id="sublabel_9_addr_line2" style="min-height:13px"> Street Address Line 2 </label> </span> </td> </tr> <tr> <td> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_9_city" name="q9_address[city]" class="form-textbox form-address-city" autoComplete="address-level2" size="21" value="" data-component="city" aria-labelledby="label_9 sublabel_9_city" /> <label class="form-sub-label" for="input_9_city" id="sublabel_9_city" style="min-height:13px"> City </label> </span> </td> <td> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_9_state" name="q9_address[state]" class="form-textbox form-address-state" autoComplete="address-level1" size="22" value="" data-component="state" aria-labelledby="label_9 sublabel_9_state" /> <label class="form-sub-label" for="input_9_state" id="sublabel_9_state" style="min-height:13px"> State / Province </label> </span> </td> </tr> <tr> <td> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_9_postal" name="q9_address[postal]" class="form-textbox form-address-postal" autoComplete="postal-code" size="10" value="" data-component="zip" aria-labelledby="label_9 sublabel_9_postal" /> <label class="form-sub-label" for="input_9_postal" id="sublabel_9_postal" style="min-height:13px"> Postal / Zip Code </label> </span> </td> <td style="display:none"> <span class="form-sub-label-container" style="vertical-align:top"> <select class="form-dropdown form-address-country noTranslate" name="q9_address[country]" id="input_9_country" data-component="country" aria-labelledby="label_9 sublabel_9_country" autoComplete="new-password"> <option value=""> Please Select </option> <option value="United States"> United States </option> <option value="Afghanistan"> Afghanistan </option> <option value="Albania"> Albania </option> <option value="Algeria"> Algeria </option> <option value="American Samoa"> American Samoa </option> <option value="Andorra"> Andorra </option> <option value="Angola"> Angola </option> <option value="Anguilla"> Anguilla </option> <option value="Antigua 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<option value="Mongolia"> Mongolia </option> <option value="Montenegro"> Montenegro </option> <option value="Montserrat"> Montserrat </option> <option value="Morocco"> Morocco </option> <option value="Mozambique"> Mozambique </option> <option value="Myanmar"> Myanmar </option> <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option> <option value="Namibia"> Namibia </option> <option value="Nauru"> Nauru </option> <option value="Nepal"> Nepal </option> <option value="Netherlands"> Netherlands </option> <option value="Netherlands Antilles"> Netherlands Antilles </option> <option value="New Caledonia"> New Caledonia </option> <option value="New Zealand"> New Zealand </option> <option value="Nicaragua"> Nicaragua </option> <option value="Niger"> Niger </option> <option value="Nigeria"> Nigeria </option> <option value="Niue"> Niue </option> <option value="Norfolk Island"> Norfolk Island </option> <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option> <option value="Northern Mariana"> Northern Mariana </option> <option value="Norway"> Norway </option> <option value="Oman"> Oman </option> <option value="Pakistan"> Pakistan </option> <option value="Palau"> Palau </option> <option value="Palestine"> Palestine </option> <option value="Panama"> Panama </option> <option value="Papua New Guinea"> Papua New Guinea </option> <option value="Paraguay"> Paraguay </option> <option value="Peru"> Peru </option> <option value="Philippines"> Philippines </option> <option value="Pitcairn Islands"> Pitcairn Islands </option> <option value="Poland"> Poland </option> <option value="Portugal"> Portugal </option> <option value="Puerto Rico"> Puerto Rico </option> <option value="Qatar"> Qatar </option> <option value="Republic of the Congo"> Republic of the Congo </option> <option value="Romania"> Romania </option> <option value="Russia"> Russia </option> <option value="Rwanda"> Rwanda </option> <option value="Saint Barthelemy"> Saint Barthelemy </option> <option value="Saint Helena"> Saint Helena </option> <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option> <option value="Saint Lucia"> Saint Lucia </option> <option value="Saint Martin"> Saint Martin </option> <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option> <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option> <option value="Samoa"> Samoa </option> <option value="San Marino"> San Marino </option> <option value="Sao Tome and Principe"> Sao Tome and Principe </option> <option value="Saudi Arabia"> Saudi Arabia </option> <option value="Senegal"> Senegal </option> <option value="Serbia"> Serbia </option> <option value="Seychelles"> Seychelles </option> <option value="Sierra Leone"> Sierra Leone </option> <option value="Singapore"> Singapore </option> <option value="Slovakia"> Slovakia </option> <option value="Slovenia"> Slovenia </option> <option value="Solomon Islands"> Solomon Islands </option> <option value="Somalia"> Somalia </option> <option value="Somaliland"> Somaliland </option> <option value="South Africa"> South Africa </option> <option value="South Ossetia"> South Ossetia </option> <option value="South Sudan"> South Sudan </option> <option value="Spain"> Spain </option> <option value="Sri Lanka"> Sri Lanka </option> <option value="Sudan"> Sudan </option> <option value="Suriname"> Suriname </option> <option value="Svalbard"> Svalbard </option> <option value="eSwatini"> eSwatini </option> <option value="Sweden"> Sweden </option> <option value="Switzerland"> Switzerland </option> <option value="Syria"> Syria </option> <option value="Taiwan"> Taiwan </option> <option value="Tajikistan"> Tajikistan </option> <option value="Tanzania"> Tanzania </option> <option value="Thailand"> Thailand </option> <option value="Timor-Leste"> Timor-Leste </option> <option value="Togo"> Togo </option> <option value="Tokelau"> Tokelau </option> <option value="Tonga"> Tonga </option> <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option> <option value="Trinidad and Tobago"> Trinidad and Tobago </option> <option value="Tristan da Cunha"> Tristan da Cunha </option> <option value="Tunisia"> Tunisia </option> <option value="Turkey"> Turkey </option> <option value="Turkmenistan"> Turkmenistan </option> <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option> <option value="Tuvalu"> Tuvalu </option> <option value="Uganda"> Uganda </option> <option value="Ukraine"> Ukraine </option> <option value="United Arab Emirates"> United Arab Emirates </option> <option value="United Kingdom"> United Kingdom </option> <option value="Uruguay"> Uruguay </option> <option value="Uzbekistan"> Uzbekistan </option> <option value="Vanuatu"> Vanuatu </option> <option value="Vatican City"> Vatican City </option> <option value="Venezuela"> Venezuela </option> <option value="Vietnam"> Vietnam </option> <option value="British Virgin Islands"> British Virgin Islands </option> <option value="Isle of Man"> Isle of Man </option> <option value="US Virgin Islands"> US Virgin Islands </option> <option value="Wallis and Futuna"> Wallis and Futuna </option> <option value="Western Sahara"> Western Sahara </option> <option value="Yemen"> Yemen </option> <option value="Zambia"> Zambia </option> <option value="Zimbabwe"> Zimbabwe </option> <option value="other"> Other </option> </select> <label class="form-sub-label" for="input_9_country" id="sublabel_9_country" style="min-height:13px"> Country </label> </span> </td> </tr> </tbody> </table> </div> </li> <li class="form-line" data-type="control_email" id="id_10"> <label class="form-label form-label-top form-label-auto" id="label_10" for="input_10"> Email </label> <div id="cid_10" class="form-input-wide"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="email" id="input_10" name="q10_email" class="form-textbox validate[Email]" size="30" value="" data-component="email" aria-labelledby="label_10 sublabel_input_10" /> <label class="form-sub-label" for="input_10" id="sublabel_input_10" style="min-height:13px"> [email protected] </label> </span> </div> </li> <li class="form-line" data-type="control_phone" id="id_11"> <label class="form-label form-label-top form-label-auto" id="label_11" for="input_11_area"> Phone Number </label> <div id="cid_11" class="form-input-wide"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" id="input_11_area" name="q11_phoneNumber[area]" class="form-textbox" size="6" value="" data-component="areaCode" aria-labelledby="label_11 sublabel_11_area" /> <span class="phone-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="input_11_area" id="sublabel_11_area" style="min-height:13px"> Area Code </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" id="input_11_phone" name="q11_phoneNumber[phone]" class="form-textbox" size="12" value="" data-component="phone" aria-labelledby="label_11 sublabel_11_phone" /> <label class="form-sub-label" for="input_11_phone" id="sublabel_11_phone" style="min-height:13px"> Phone Number </label> </span> </div> </div> </li> <li id="cid_12" class="form-input-wide" data-type="control_head"> <div class="form-header-group "> <div class="header-text httal htvam"> <h2 id="header_12" class="form-header" data-component="header"> Replacement Qualification Certificate Requested </h2> </div> </div> </li> <li class="form-line" data-type="control_textbox" id="id_13"> <label class="form-label form-label-top form-label-auto" id="label_13" for="input_13"> Full title of qualification </label> <div id="cid_13" class="form-input-wide"> <input type="text" id="input_13" name="q13_fullTitle" data-type="input-textbox" class="form-textbox" size="50" value="" data-component="textbox" aria-labelledby="label_13" /> </div> </li> <li class="form-line" data-type="control_textbox" id="id_14"> <label class="form-label form-label-top form-label-auto" id="label_14" for="input_14"> Level and year of award (if known) </label> <div id="cid_14" class="form-input-wide"> <input type="text" id="input_14" name="q14_levelAnd" data-type="input-textbox" class="form-textbox" size="50" value="" data-component="textbox" aria-labelledby="label_14" /> </div> </li> <li id="cid_15" class="form-input-wide" data-type="control_head"> <div class="form-header-group "> <div class="header-text httal htvam"> <h2 id="header_15" class="form-header" data-component="header"> Reason for request (select one) </h2> </div> </div> </li> <li class="form-line" data-type="control_radio" id="id_16"> <label class="form-label form-label-top form-label-auto" id="label_16" for="input_16"> Reason for request (select one) </label> <div id="cid_16" class="form-input-wide"> <div class="form-single-column" role="group" aria-labelledby="label_16" data-component="radio"> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_16_0" name="q16_reasonFor16" value="Lost and/or damaged in transit" /> <label id="label_input_16_0" for="input_16_0"> Lost and/or damaged in transit </label> </span> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_16_1" name="q16_reasonFor16" value="Lost or stolen" /> <label id="label_input_16_1" for="input_16_1"> Lost or stolen </label> </span> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_16_2" name="q16_reasonFor16" value="Not received" /> <label id="label_input_16_2" for="input_16_2"> Not received </label> </span> </div> </div> </li> <li id="cid_17" class="form-input-wide" data-type="control_head"> <div class="form-header-group "> <div class="header-text httal htvam"> <h2 id="header_17" class="form-header" data-component="header"> Items enclosed (select) </h2> </div> </div> </li> <li class="form-line" data-type="control_checkbox" id="id_19"> <label class="form-label form-label-top form-label-auto" id="label_19" for="input_19"> Proof of identity enclosed: </label> <div id="cid_19" class="form-input-wide"> <div class="form-single-column" role="group" aria-labelledby="label_19" data-component="checkbox"> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" class="form-checkbox" id="input_19_0" name="q19_proofOf[]" value="Passport or national ID card" /> <label id="label_input_19_0" for="input_19_0"> Passport or national ID card </label> </span> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" class="form-checkbox" id="input_19_1" name="q19_proofOf[]" value="Driving Licence" /> <label id="label_input_19_1" for="input_19_1"> Driving Licence </label> </span> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" class="form-checkbox" id="input_19_2" name="q19_proofOf[]" value="Birth or marriage certificate" /> <label id="label_input_19_2" for="input_19_2"> Birth or marriage certificate </label> </span> </div> </div> </li> <li class="form-line" data-type="control_radio" id="id_20"> <label class="form-label form-label-top form-label-auto" id="label_20" for="input_20"> Original certificate enclosed? </label> <div id="cid_20" class="form-input-wide"> <div class="form-single-column" role="group" aria-labelledby="label_20" data-component="radio"> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_20_0" name="q20_originalCertificate" value="Yes" /> <label id="label_input_20_0" for="input_20_0"> Yes </label> </span> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_20_1" name="q20_originalCertificate" value="No" /> <label id="label_input_20_1" for="input_20_1"> No </label> </span> </div> </div> </li> <li id="cid_21" class="form-input-wide" data-type="control_head"> <div class="form-header-group "> <div class="header-text httal htvam"> <h2 id="header_21" class="form-header" data-component="header"> Declaration </h2> </div> </div> </li> <li class="form-line" data-type="control_text" id="id_22"> <div id="cid_22" class="form-input-wide"> <div id="text_22" class="form-html" data-component="text"> <p>I confirm that by completing and submitting this form, I:</p> <p>· give consent to the processing of this data;</p> <p>· have read and understand the UNC guidance document on replacement certificates;</p> <p>· have supplied information which to the best of my knowledge is correct</p> </div> </div> </li> <li class="form-line" data-type="control_signature" id="id_25"> <label class="form-label form-label-top form-label-auto" id="label_25" for="input_25"> Signature </label> <div id="cid_25" class="form-input-wide"> <div data-wrapper-react="true"> <div id="signature_pad_25" class="signature-pad-wrapper" style="width:402px;height:202px"> <div data-wrapper-react="true"> <!--[if IE 7]> <script type="text/javascript" src="/js/vendor/json2.js"></script> <![endif]--> </div> <div class="signature-line signature-wrapper" data-component="signature" style="width:402px;height:202px"> <div id="sig_pad_25" data-width="400" data-height="200" data-id="25" data-required="false" class="pad "> </div> <input type="hidden" name="q25_signature" class="output4" id="input_25" /> </div> <span class="clear-pad-btn clear-pad"> Clear </span> </div> <div data-wrapper-react="true"> <script type="text/javascript"> window.signatureForm = true </script> </div> </div> </div> </li> <li class="form-line" data-type="control_datetime" id="id_24"> <label class="form-label form-label-top form-label-auto" id="label_24" for="lite_mode_24"> Date </label> <div id="cid_24" class="form-input-wide"> <div data-wrapper-react="true"> <div style="display:none"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="month_24" name="q24_date[month]" size="2" data-maxlength="2" value="" aria-labelledby="label_24 sublabel_24_month" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="month_24" id="sublabel_24_month" style="min-height:13px"> Month </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="day_24" name="q24_date[day]" size="2" data-maxlength="2" value="" aria-labelledby="label_24 sublabel_24_day" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="day_24" id="sublabel_24_day" style="min-height:13px"> Day </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="year_24" name="q24_date[year]" size="4" data-maxlength="4" value="" aria-labelledby="label_24 sublabel_24_year" /> <label class="form-sub-label" for="year_24" id="sublabel_24_year" style="min-height:13px"> Year </label> </span> </div> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_24" size="12" data-maxlength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="mm-dd-yyyy" aria-labelledby="label_24 sublabel_24_litemode" /> <img alt="Pick a Date" id="input_24_pick" src="https://cdn.jotfor.ms/images/calendar.png" style="vertical-align:middle;margin-left:5px" data-component="datetime" aria-hidden="true" /> <label class="form-sub-label" for="lite_mode_24" id="sublabel_24_litemode" style="min-height:13px"> Date </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <label class="form-sub-label" for="input_24_pick" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap"> Date Picker Icon </label> </span> </div> </div> </li> <li class="form-line" data-type="control_button" id="id_2"> <div id="cid_2" class="form-input-wide"> <div style="margin-left:156px" class="form-buttons-wrapper "> <button id="input_2" type="submit" class="form-submit-button" data-component="button"> Submit </button> </div> </div> </li> <li style="display:none"> Should be Empty: <input type="text" name="website" value="" /> </li> </ul> </div> <!-- [et_pb_line_break_holder] --></form>