POST SECONDARY APPLICATION

A. Basic Student Information

First Name:

Middle Initial:

Last Name:

Gender: Male Female

Birthday (Day/Month/Year):

Treaty Number:

Social Insurance Number:

Marital Status

Address:

Address2:

City:

Province/State:

Postal Code:

Email Address:

Home Phone:

Fax Number:

Business Phone:

Cellular Phone:

Are you currently employed?: Yes No

Income Source and amount per year:

Have you recieved E.I.?: Yes No

B. Previous and Current Education

High School attended:

City:
Province/State:
Postal Code:

Dates Attended:

From (Month/Year)

To (Month/Year)

Diploma Recieved: Yes No

Highest Grade Completed:

University, College, Technical Institute:

City:
Province/State:
Postal Code:

Dates Attended:

From (Month/Year)

To (Month/Year)

Completed: Yes No

If Completed: Degree, Diploma, or Certificate obtained:

C. Marital/Family Information

Marital Status

Name of Spouse:

Address:
City:
Province/State:
Postal Code:

Treaty Number of Spouse:

Member of which First Nation:

Employment Status of Spouse:

If Spouse is empoyed, where:

Address:
City:
Province/State:
Postal Code:

Annual Income:

If Spouse is unemployed, source of income:

DEPENDANTS

Name:
Birthdate (m/d/y):

Name:
Birthdate (m/d/y):

Name:
Birthdate (m/d/y):

Name:
Birthdate (m/d/y):

Name:
Birthdate (m/d/y):

Name:
Birthdate (m/d/y):

Are they currently residing with you: Yes No

Do You or your spouse recieve any income for their support (child tax benefits, child support, maintenance, trust-fund): Yes No

If Yes, amount per month:

D. Assistance Requested

Have you been accepted to post secondary institution: Yes Unknown at this time

If yes, please mail a copy of the letter of acceptance.

Institution:

Program/Faculty/College:

Location:

City:

Province:

Major Specialization:

Length of Program:

Program: Attendance:

Expected Completion date:

Practicum: Yes No

If Yes, when and how long:

Assistance requested:

Assistance for this acedemic year to commence (Month/Year to Month/Year):

Are you applying for a student loan: Yes No

E. Career Planning

What factors influenced your decision to attend post secondary education?:

Have you completed a career study?: Yes No

Who are what resources have you checked with regard to your career path?:

What are your long term goals related to post secondary education?:

F. Complete if you have previously accesed post secondary education funding from any source including English River Post Secondary Program.

What source(s) of funding have you previously accessed for post secondary education?:

For what education/training program?:

Were you successful in completing the requirements of the course?: Yes No

What steps have you taken to ensure your successful completion of this training/education?:

I, , authorize the English River Post Seconadary Program to access information concerning my academic records at the institution I am attending. I accept responsibility for satisfying the academic requirements of the institution and managing the education assistance funds to the best of my ability. I will complete a student monitoring report/progress report/cumulative record signed by an authorized program/academic advisor at the institution of study and will forward a copy to the English River Post Secondary Program before the term ends. I will submit a copy of final marks at the end of each term and a declaration of full-time attendance each month.

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