part-time program application form - the michener institute · print clearly authorization and...

Part-Time Program Application Registrar’s Office - Admissions 222 St. Patrick Street Toronto, ON M5T 1V4 [email protected] │ 1 (416) 596-3117 or 1 (800) 387-9066 Part-Time Program Application Form (1) 2020-05-29 Date Received Office Use Only PERSONAL INFORMATION LAST NAME FIRST NAME MIDDLE NAME STUDENT ID # (former students) DATE OF BIRTH (MM/DD/YYYY) ________ /________ /___________ GENDER: [ ] Female [ ] Male [ ] Other COUNTRY OF CITIZENSHIP [ ] Canadian [ ] Other _________________________________ LANGUAGE (FIRST) [ ] English [ ] French [ ] Other: ______________________ VISA STATUS [ ] International Student [ ] International Student with Study Permit [ ] Permanent Resident [ ] Protected Person/Refugee CONTACT INFORMATION Tick this box if you would like to update the address on file with the address below. ADDRESS CITY OR TOWN PROVINCE POSTAL CODE TELEPHONE (_______) ___________ -__________________ EMAIL ADDRESS PROGRAM SELECTION - $35.00 Application Fee - One Form Per Program Choice ($95.00 for International Applicants) PROGRAMS (must apply before registering for courses) Bridging Programs PROGRAMS (can complete courses before applying to program) PLANNED START DATE (MM/YYYY): ______ /________ APPLICATION FEE - PAYMENT METHOD Cash (in person only) Debit (in person only) Credit Card (Visa, MC, AMEX) Money Order (or Certified Cheque) Card #: ________________________________________ Expiry Date: _________________________ Enter Numbers Only – No Spaces MM/YY Name: _________________________________________ Signature: ___________________________ PRINT CLEARLY AUTHORIZATION AND DECLARATION I understand that if any information in my application is determined to be false or misleading, concealed or withheld, my application may be invalidated and this could result in its immediate rejection or in the revocation of an offer of admission or registration at The Michener Institute of Education at UHN. I, the undersigned, declare that all application information and all supporting documentation are truthful, complete and correct. Student Signature: ____________________________________________________________ Date: _________________ OFFICE USE ONLY: Processed By: ___________________________________________________________________ Registrar’s Office Staff Name Date ________________________ The information on this form is collected under the authority of the Michener Institute of Education at UHN and will be protected and used in compliance with the Ontario Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. Student information held by the Michener Institute of Education at UHN may be used for administrative and statistical purposes of the Institute and/or the ministries and agencies of the Government of Ontario and the Government of Canada.

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Part-Time Program Application Registrar’s Office - Admissions

222 St. Patrick Street Toronto, ON M5T 1V4 [email protected] │ 1 (416) 596-3117 or 1 (800) 387-9066

Part-Time Program Application Form (1) 2020-05-29

Date Received Office Use Only

PERSONAL INFORMATION

LAST NAME FIRST NAME MIDDLE NAME STUDENT ID # (former students)

DATE OF BIRTH (MM/DD/YYYY) ________ /________ /___________ GENDER: [ ] Female [ ] Male [ ] Other

COUNTRY OF CITIZENSHIP

[ ] Canadian [ ] Other _________________________________

LANGUAGE (FIRST)

[ ] English [ ] French [ ] Other: ______________________

VISA STATUS

[ ] International Student [ ] International Student with Study Permit [ ] Permanent Resident [ ] Protected Person/Refugee

CONTACT INFORMATION Tick this box if you would like to update the address on file with the address below.

ADDRESS CITY OR TOWN PROVINCE

POSTAL CODE TELEPHONE

(_______) ___________ -__________________

EMAIL ADDRESS

PROGRAM SELECTION - $35.00 Application Fee - One Form Per Program Choice ($95.00 for International Applicants) PROGRAMS (must apply before registering for courses)

Bridging Programs

PROGRAMS (can complete courses before applying to program)

PLANNED START DATE (MM/YYYY): ______ /________

APPLICATION FEE - PAYMENT METHOD

Cash (in person only)

Debit (in person only)

Credit Card (Visa, MC, AMEX)

Money Order (or Certified Cheque)

Card #: ________________________________________ Expiry Date: _________________________ Enter Numbers Only – No Spaces MM/YY

Name: _________________________________________ Signature: ___________________________ PRINT CLEARLY

AUTHORIZATION AND DECLARATION

I understand that if any information in my application is determined to be false or misleading, concealed or withheld, my application may be invalidated and this could result in its immediate rejection or in the revocation of an offer of admission or registration at The Michener Institute of Education at UHN. I, the undersigned, declare that all application information and all supporting documentation are truthful, complete and correct.

Student Signature: ____________________________________________________________ Date: _________________

OFFICE USE ONLY:

Processed By: ___________________________________________________________________ Registrar’s Office Staff Name Date ________________________

The information on this form is collected under the authority of the Michener Institute of Education at UHN and will be protected and used in compliance with the Ontario Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. Student information held by the Michener Institute of

Education at UHN may be used for administrative and statistical purposes of the Institute and/or the ministries and agencies of the Government of Ontario and the Government of Canada.

mailto:[email protected]

LAST NAME: FIRST NAME: MIDDLE NAME: STUDENT ID former students: undefined: undefined_2: undefined_3: undefined_4: undefined_5: ADDRESS: CITY OR TOWN: PROVINCE: POSTAL CODE: undefined_6: undefined_7: undefined_8: EMAIL ADDRESS: undefined_9: undefined_10: Card: Expiry Date: Name: Date: Processed By: Date_2: Dropdown3: [Please select a program from the drop down list]Dropdown5: [Please select a program from the drop down list]Dropdown7: [Please select a program from the drop down list]Text8: Check Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffText26: