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Citizenship*

Personal Information

Family Name:*
Gender
Given Name:*
Birth Date:*
Address:*
Postal/ZipCode:*
City:*
Province/State:*
Country:*
Home Phone:
Student E-Mail Address:*
Mobile:*
First Language
Self-assessed language level
Street Address in Canada (if available and different from above)

Status

ImmigrationStatus*
If Other - Please specify:
Expiry Date:

Emergency Contact in your home country

Emergency Contact Full Name*
Emergency Contact Telephone*
Emergency Contact Address

Voluntary Disclosure

*You may voluntarily provide the personal information listed below:

Do you identify yourself as an Aboriginal person, that is, First Nations, Métis, or Inuit?

If you answered “Yes”, please indicate if you are:

First Nations
Métis
Inuit

Do you have a long-term physical or mental health condition that limits the kind of activity that you can perform on a daily basis?

Disability
If yes, are you requesting accomodation?

How did you hear about SELC?

How did you hear about us?
Please Specify

Study Selection

Program:*
Program Schedule(Not Guarantee)
Desired Start Date*
Payment Plan Request (9 month,1 or 2 years program only)

Medical

Do you want SELC to arrange Medical Insurance?
Medical Insurance Start Date
Medical Insurance End Date

Homestay

Do you want SELC to arrange accommodation (homestay) for you?
Accommodation Type
Meals

Details

# Nights
# Weeks
Check-in Date
Check-out Date
Do you smoke?: If yes, you must agree to smoke outside.

Are you OK living with pets?

Yes - Pets
Please specify - Pets
No - Pets

Are you OK living with children?

Yes - Children
Please specify - Children
No - Children

Do you have any allergies?

Yes - Allergies
Please specify - Allergies
No - Allergies

Special requests or needs?

Special requests or needs? (Please specify)

Airport Pickup Requested

Yes
Arrival Date:
No
Time:
Airline & Flight No.

Please upload the following documents:
1. copy of passport
2. copy of diploma (high school, college or university). Or, a copy of attendance records from University.
3. Student Visa
4. Work Visa
5. Proof of English ability (example IELTS, TOEFL)

 

Documents
  
By submitting this form, I agree that SELC Career College Canada may call, text and/or email me about their educational services