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Section A: Personal Information


Middle Name:

Last Name:

Gender:  M F

Previous Last Name(if changed):

Date of Birth:

Status in Canada

 Canadian Citizen Permanent Resident Student Authorization(visa) Other:

Country of Citizenship: :

Passport Number: :

First Language: :

Address: :   

Telephone #:


Academic Information:
Are you or will be a secondary school graduate? (if yes,attach transcripts and certificate)  yes no


 Mail Fax to Follow

Graduate Certificate

 Mail Fax to Follow

Section B: Course Information

 Pre-University Program Advanced Program Express Program Credit Courses Intensive Training

Course Name (code) Your Level Start Date End Date

Section C: Application Fee ---$200

*application fee is not refundable under any kind of conditions.
I confirm that I have read and accepted conditions of application as well as the refund policies of the NIC as stated in this form.

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