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GRADUATE STUDIES NEEDS ASSESSMENT FORM All students must complete

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GRADUATE STUDIES NEEDS ASSESSMENT FORM All students must complete Powered By Docstoc
					GRADUATE STUDIES NEEDS ASSESSMENT FORM
All students must complete this form in order to receive Graduate Funding
PERSONAL INFORMATION
Last name First name Social Insurance Number Student Number

Home address

City, Province, Postal Code

Phone number

Citizenship status: (please check)

Name of Graduate Program

Canadian citizen

Permanent Resident

Student Visa
Yes No

Have you applied or will you apply for Federal/Provincial student aid (eg. OSAP) for the 2009-2010 session? If no, please explain on a separate sheet

STUDENT STATUS (Please check applicable box and provide relevant details) I am married
Spouse’s name Spouse’s Social Insurance Number

What will spouse’s status be at the beginning of your study period?

full-time post-secondary student employed other

If spouse is a full-time post-secondary student, where will he/she be studying? Enter spouse’s total gross income for 2008. Include all sources of taxable and nontaxable income, such as income from employment, government benefits, alimony and child-support payments and lottery winnings, etc Is main source of spousal income provincial social assistance? INFORMATION ABOUT CHILDREN Number of children 0 – 11 years of age What is total amount you expect to pay for child care during your studies? Number of children 12 years of age or older $ Yes No $

Type of provincial social assistance:

I am a sole support parent
Number of children 0 – 11 years of age What is total amount you expect to pay for child care during your studies? Number of children 12 years of age or older $

I am single, with no dependants
Where will you be living during the study period? with parents Yes away from home No

Do you receive a tuition exemption or are your fees being paid by a third party? Specify:

INCOME TO BE RECEIVED Estimated Summer savings (May – August 2009) INCOME DURING THE STUDY PERIOD (Sept, 2009 to August, 2010) Nipissing University Funding Part-time earnings while in school (other than T.A. or R.A.) Social assistance/Government income (ex. CPP/EI/ODSP, etc...) Sponsorship (ex. Native Support, WSIB, HRDC etc...) Parent contribution Scholarships/Bursaries/OGS/NSERC/OGSST (Do not include Fellowship) Financial support from supervisor (not including T.A. & R.A. included in $5000 funding) OSAP or other federal/provincial student loan assistance Student Line of Credit Other (all other income and/or investments cashed for use in 2009/10) TOTAL INCOME Comments or additional information
$5000 $ $ $ $ $ $ $ $ $ $ $

DECLARATION I declare that the above information is true and correct, and I understand that this information could be subject to verification by Nipissing University. I understand that any award granted will first be applied to any outstanding fees I might owe the university. I also realize that any financial assistance received may reduce my OSAP entitlement and/or may cause an overaward.
Signature
Date

PLEASE SUBMIT COMPLETED APPLICATION TO: STUDENT AWARDS & FINANCIAL AID OFFICE, NIPISSING UNIVERSITY BOX 5002, 100 COLLEGE DR., NORTH BAY, ON P1B 8L7
Protection of privacy The information on this form is collected under the authority of the Nipissing University Act, 1992. The University uses relevant personal information on this form to administer scholarships, bursaries, awards, loans, work study, and OSAP for the purposes of determining eligibility, verifying the application and calculating entitlements. The personal information may be disclosed to employees of the university, donors, the federal government, and ministries of the Ontario government for the purpose of notification and verification of the application of any award. If you have any questions about the collection, use, and disclosure of this information please contact the Financial Aid Office, Nipissing University, 100 College Drive, North Bay, ON P1B 8L7, (705) 474-3450 ext. 4297.

OFFICE USE
Date
FAO signature

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