"INTERNATIONAL STUDENT PROGRAM APPLICATION"
OFFICE USE ONLY Student Number Status INTERNATIONAL STUDENT PROGRAM APPLICATION Please submit a completed application form together with an application fee of $100 US for each program to which you are applying. Please Print Clearly Program Applying For: (If you have previously attended Social Insurance Number* Student Number Assiniboine Community College) Are you applying as a Full-time Part-time Student Student Campus Preferred Start Date Brandon Dauphin Other Year Month 12 Required Information* Legal Name* Mr. Mrs. Miss Ms. Previous last name, if applicable: Last Name First Second Preferred P.O. Box or Number and Street City or Town Permanent* Home Address Postal Code Country Province P.O. Box or Number and Street City or Town Mailing* Address (if different from above) Postal Code Country Province Email Address* Gender* M F Home Telephone Number Date of Birth* Year Month Day Other Telephone Number Country of citizenship For students already in Canada: Do you have a Study Permit? Yes No Expiry Date (If yes, please include a photocopy of your permit.) Aboriginal Status Non-Status Métis Inuit Visible Minority Yes No (Persons in a visible minority group in Canada are defined under the Employment Equity regulations as persons other than Aboriginal peoples who are non-white in colour or non-caucasian.) English Language Proficiency What is your first language (language first spoken and still understood) Please see Application Guide. An English Language Assessment is required from applicants whose first language is not English. A list of acceptable tests and minimum scores as well as a list of countries from which students will not be required to provide proof of English Proficiency can be found on our website: www.assiniboine.net. Have you written the TOEFL or another test or another test of English Language? Yes No If yes: Test Date Written Score Scores must be forwarded directly from the test centre. Emergency Name Address Telephone Contact EDUCATIONAL BACKGROUND Please attach your most recent high school transcript (original) AND transcripts from other post-secondary institutions. Secondary Education High School Attended (No Abbreviations Please) Province or Country Last date attended or Highest grade level completed graduation day (mo/yr) Post-Secondary Education University or College Program Province or Country Dates Attended Highest Credential Obtained Use of Agents or other Representatives Are you using an agent or official representative? Yes No Do you have any other contact in Canada who may be acting on your behalf? Yes No If yes, please provide the following information. Representative or other Contact Name Representative Company (if applicable) Address City Province/State Business Telephone Number Home Phone Number Email Address Do you wish us to send official correspondence related to your application to you at your permanent mailing address? to your agent or representative? Note: No information will be provided, either verbally or in writing, to any individual except yourself without your authorization below. Release of Information Authorization: I hereby authorize Assiniboine Community College to release academic and other information to the above named contact as deemed necessary. Signature Date Please rank the top three sources (by number) that influenced you to apply, (1) being the most influential. Agent Friend/Relative ACC Website Canadian Education Centre Canadian Embassy Study in Canada Guidebook Education/Career Fair Teacher/Counsellor Other Website Other DECLARATION • I declare that I have read and understood the information on this application and guide, including the Notice Regarding Collection, Use and Disclosure of Personal Information, and that all statements made with respect to this application are true and complete. • I understand that misrepresentation, falsification of documents, or the withholding of requested information with respect to this application can result in cancellation of the acceptance and registration, or dismissal from the College. • I accept that any information on falsified documents may be shared with the Association of Registrars of the Universities and Colleges of Canada. • I authorize my high school/college/university to release my academic record(s) for admission purposes should the need arise to accelerate the processing of this application. • I agree, if admitted, to comply with the regulations of Assiniboine Community College. Signature of Applicant Date I have included all required official transcripts/documents and the $100 US application fee in the form of: Cheque/Money Order (Payable to Assiniboine Community College) Visa MasterCard Credit Card # Expiry date Cardholder Signature