Middle name: Former surname (if applicable):
Current address valid until (DD/MM/YY):
Mount A mailbox (if applicable):
Status in Canada:Permanent resident Student visa — entry date (dd/mm/yy): Other visa — entry date (dd/mm/yy):
Place of birth:
Date of birth (DD/MM/YY):
Emergency contact information
Relationship to applicant:
Proposed field of study:
Specially approved field:
Attendance at previous universities Include all post-secondary institutions attended.
2. Degree/diploma: Year obtained: Years attended: Institution:
3. Degree/diploma: Year obtained: Years attended: Institution:
Names and addresses of two references:
I hereby certify that all of the information is correct and I agree to follow and be bound by the regulations of the University, including any revisions, deletions, or additions made to them in the future. I agree to pay all fees associated with my registration and enrolment at the University.