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					                                                                                     School of Graduate Studies
                                                                                  GRADUATE AWARDS OFFICE

     2011-2012 CONCORDIA UNIVERSITY RETIRED FACULTY AND STAFF
                         GRADUATE AWARDS

        These Awards are for Canadian Citizens or Permanent Residents
GENERAL INFORMATION (All information must be typed or printed clearly)

 FAMILY NAME Please print family name in capital letters                                              SOCIAL INSURANCE NUMBER

 | | | | | | | | |                                | | | | | | | |                                       | | | | | | | |

                                                                                                                                elaM □
 GIVEN NAME                                                                       FORMER BIRTH NAME

    | | |            | | | | |                  | | | | | |                            | | | | | | | |                   |
                                                                                                                                eMalaM□
 EMAIL                                                                                                       ID NUMBER

  | | | | | | | | | | | | | | | | |                                                     | |                     | |          | | | |
□ADDRESS (for correspondence)

 STREET NUMBER/NAME                                                   APT. NO                         MUNICIPALITY

    | | | | | | | |                             | | | | | | | |                    |       |           | | | | | | | | |
 PROVINCE/STATE/COUNTRY                              POSTAL CODE                PHONE NUMBER (HOME)             PHONE NUMBER (OFFICE)

   | | | | | | |                                           | | | | |            | | | | | | | | |                | | | - | | | |

MARITAL STATUS (Please attach supporting documents)

            □             elgnaM                           □   elrrlMM                 □       wlllgn mgaagg alL
            □             eMiMrlelgn                       □   ellgrmM                 □       olMgL

Is your spouse with you in Canada?                             No □                    Yes □
?eg dgi llM MMiMgMMge m laMrMg                                 No □                    Yes □   ygL algd
?arM dgir m laMrMg Lle dgi lg olglMl                           No □                    Yes □   ygL algd
How old are your children?

ACADEMIC HISTORY (Please provide the following document)

            1) Unofficial transcripts of all university studies (bachelor, master, doctoral);
            2) A statement describing your financial situation and explaining how a scholarship will assist you

Program of study for which scholarship is being sought:                                        □ Master’s □ Doctoral

Discipline:                                                        Date of entry in the program:

SUBMIT COMPLETED APPLICATION
Completed applications must be received by the application deadline with all required documents attached.
Applications are to be submitted to:  TO YOUR DEPARTMENT

DEADLINE DATE:                  Please check with your department

SCHOOL OF GRADUATE STUDIES                                               1/3                                          07/08
NAME:                                                                                   ID:

PROGRAM:
APPLICANTS FINANCIAL SITUATION
On a separate piece of paper describe your financial situation and explain how a scholarship would
be of assistance to you. In describing your situation, indicate whether you are privately sponsored,
sponsored by an organization, company, or self-supporting.

If you have a sponsor, does your sponsor pay your tuition fees?    No    □    Yes   □

Please provide a detailed budget for the period of May 1, 2009 to April 30, 2010.


                 STUDENT FINANCIAL INFORMATION
INCOME (May 2009-April 2010)    ANNUAL EXPENSES (May 2009 April
                                2010). You are not required to provide
                                information concerning rent, food,
                                clothing, utilities, tuition, books or
                                transportation on the Island of Montreal.
                                These amounts are standardized.

Work Income:                                            $            * Denotes documentation required
Teaching Assistant/Research Ass
Summer 2009                                             $
Fall 2009                                               $
Winter 2010                                             $
Alimony/Child Support:                                  $            * Medical:                        $
Bursary/Scholarship/ Education                          $
Saving Plan:
Interest on Investment:                                 $            * Daycare expenses:               $
Contribution from:                                      $            Alimony/Child Support:            $
 □ Parents □ Spouse □ Family
Government Family Allowance
Provincial:
Federal:
Other (please specify):                                 $            Other (please specify):           $
Total:                                                  $            Total:                            $

                         Married Individuals – Spouse Financial Information
To be completed by those students who are either legally married or living as though married. Please
provide a copy of your marriage certificate (if legally married) along with a copy of your spouse’s 2008
Income tax forms. Please indicate income of spouse as of January 2008 to December 2008. In addition,
please submit birth certificates for all dependent children.
Work Income:                                        $                Loans and/or Bursaries:           $
Employment Insurance Income:                        $                Scholarship and/or Fellowships:   $
Social Aid:                                         $                Interest on Investment:           $
Alimony/Child Support:                              $                Other (please specify):           $
Total:                                              $                Total:                            $
School of Graduate Studies                                         2/3                                 08/09
INCOMPLETE APPLICATIONS SUBMITTED TO THE COMPETITION WILL BE
ELIMINATED. ONLY COMPLETE APLICATIONS WILL BE REVIEWED.




THIS DECLARATION IS TO BE SIGNED BY ALL APPLICANTS

I do hereby declare that the information provided on this application and on the documents which
accompany it are true, accurate, and complete.

An important part of the University’s relationship with its donors is the preparation of annual reports about
the status of donated funds, and confirmation to donors that recipients have been selected for their
fellowships, scholarships, awards, teaching assistantships. In addition to confirming the status and value of
the fellowship/scholarship/award/teaching assistantship to donors, the recipient information provided in
these annual donor reports includes:
     i)       Student’s last name & first name
     ii)      Student’s program of study (e.g. M.A.Sc. Mechanical Engineering),

By applying to the award and should my application be successful, I hereby agree to the release of the
information contained in my application (including the information listed above) to the donor of the
fellowship, scholarship, award, or teaching assistantship and for the purpose of including such information
in the annual report as well as for use in marketing materials and publications.




Signature:                                                       Date:




FOR OFFICE USE ONLY                          Application received:
                                             Verified by:

                                             Notes:




School of Graduate Studies                            3/3                                          08/09

				
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