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					                                                                                                                                    1638 10th Ave SW
                                                                                                                                  Calgary, AB T3C 0J5
              CDTC                                                   Calgary Dental                                                Phone: 403.244.6053
                                                                                                                                     Fax: 403-264-5410
                                                                 Technology College                                                Website: www.cdtc.ca
                                                                                                                          Email: CDTCollege@gmail.com




                          2011/2012                        ADMISSION APPLICATION
  DENTAL TECHNOLOGY PROGRAM STARTING                      . 20                    OTHER PROGRAM :         ESL

PERSONAL INFORMATION
LAST NAME                                                 FIRST NAME                                     SECOND NAME


MAILING ADDRESS                                                                   POSTAL CODE            EMAIL ADDRESS


HOME PHONE NUMBER                                      CELL PHONE NUMBER                                 FAX PHONE NUMBER


BIRTH DATE(MM/DD/YY)                    SOCIAL INSURANCE NUMBER                              MARITAL STATUS            GENDER
                                                                                                                           FEMALE           MAIL

CTIZENSHIP STATUS                                                       DATE OF CANADIAN ENTRY    COUNTRY OF ORIGIN       FIRST LANGUAGE SPOKEN
                                                                              (MM/DD/YY)

    CANADIAN CITIZEN        PERMANENT RESIDENT          STUDENT VISA




ACADEMIC INFORMATION
DO YOU HAVE A HIGH SCHOOL DIPLOMA CERTIFICATE ?                                               IF YOU DON'T HAVE, YOU ARE GOING TO HAVE

                  YES                   NO                                     BEFORE PROGRAM STARTING DATE         BEFOREE PROGRAM FINISHING DATE

LAST HIGH SCHOOL ATTENDED                             CITY OR TOWN AND COUNTRY                   LAST YEAR OF HIGH SCHOOL ATTENDANCE



ALBERTA STUDENT ID NUMBER                              HIGH SCHOOL STATUS

                                                            ATTENDING           GRADUATING               GRADUATE               INCOMPLETE


PREVIOUS POST SECONDARY EDUCATION (INCLUDE YEARS OF STUDY)                                             LEVEL OF ACADEMIC ACHIEVEMENT


HIGH SCHOOL SUBJECTS COMPLETED OR BEING TAKEN

Please report final mark or midterm mark in space provided. If currently enrolled and no mark available, indicate in

SUBJECT                                       FINAL MARK                        MIDTERM MARK                           NOW BEING TAKEN

ENGLISH 30 OR 33

PURE MATH 20 OR APPLIED

BIOLOGY 30



MANUAL DEXTERITY TEST
MANUAL DEXTERITY TEST is a part of admission requirements

             I TOOK A TEST                    I WILL TAKE A TEST


IMMUNIZATION RECORD
All students accepted dental technology program must show the documented proofs of the following
    Measles (Rubeola)                        I HAVE                                      I WILL HAVE

    Mumps                                    I HAVE                                      I WILL HAVE

    Rubella (German measles)                 I HAVE                                      I WILL HAVE

    Hepatitis B                              I HAVE                                      I WILL HAVE


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I certify that the information provided is true and complete in all respects and that no information has been withheld. I understand
that falsifying or omitting documents or information on this application will result in immediate and permanent dismissal from The
College. Falsified documents may be referred to the appropriate authorities for prosecution of the applicant under the Criminal Code
of Canada. The College reserves the right to refuse admission or cancel any admission ruling.


The information collected on this form is collected under the authority of The Colleges Act. the Freedom of Information and
Protection of Privacy Act of Alberta, the Statistics ACT(Canada). The information will be protected in compliance with the provisions
of the Freedom of Information and Protection of Privacy Act of Alberta.

I acknowledge that the information collected on this form will be used to create records for the purpose of determining eligibility for
admission to Calgary Dental Technology College and to distribute information about college programs and services. if I am
admitted , the information will form part of my student record and will be disclosed to relevant academic and administrative
departments for the purposes of registration, operation of Calgary Dental Technology College programs and services, providing tax
receipts, determine eligibility for scholarships and awards, graduation, distributing follow-up educational information. college
research, and college alumni programming. In addition specific elements of information will be disclosed to the federal and
provincial governments to meet reporting requirements and to the Students' Association of Calgary Dental Technology College and
other cooperating educational, funding, and workplace agencies in accordance with contractual agreements. Credentials awarded
to a student are part of the public record and may be disclosed to third parties on request.

I agree, if admitted to Calgary Dental Technology College, to comply with all rules and regulations of Calgary Dental Technology
College




STUDENT SIGNATURE
                                                                           DATE OF APPLICATION




APPLICATION CHECK LIST
Transcripts                                                               Immunization Documents

                 Official High School Transcripts OR                                             Measles(Rubeola)

                 School Transcripts indicating course completed and
                 courses in progress                                                             Mumps


                 Post Secondary Transcripts (if applicable)                                      Rubella(German measles


                 GED Transcripts (if applicable)                                                 Hepatitis B


Application Fee - Non-refundable fee

                 CD$150

Processing Fee - Non-refundable fee
                  CD$150



      Please do not write in the shaded areas
               For Office Use Only


Amount paid:



Date received:




     * Please make registration fee cheques payable to the Calgary Dental Technology College.
     * Upon acceptance, you will be contacted and informed of all necessary information regarding the program of study requirements, fee
     payment structure, and course timeline details.



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Phone: 403.244.6053




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