First Name:*

Middle Name:

Last Name:*

Mobile:*

Home Phone:*

E-Mail:*

Birth Date:*

Gender

Postal/ZipCode:*

Address1:*

City:*

Country:*

Province/State:*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Telephone*

Are you a Canadian Citizen?*

Social Insurance Number (Canadian Students Only)

Citizenship*

Do you have a study permit?

Current Status In Canada:*

If you do not have a study permit, do you have a permit, visa or other written authorization to study in Canada other than study permit?

Is English your first language?

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

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?

Are you a high school graduate?

Name Of High School:

High School Grad Date

Level of Education

PEN

Name of Institution

Program of Study

Level/Year completed

Have you attended University, College or a vocational Program?

Are you currently employed?

Name of Employer:

Position:

Are you eligible to receive funding from any source?

If yes, please describe:

How did you learn about Granville College? (Part 1)*

Please Specify: (Part 2)

Program Interested in?