Education/Training Registration

This form will enable ACTLAP EDUCATION CANADA to determine your status as a potential Student and Participant and assist us in analyzing your application needs.

Note: Required fields are indicated with an *.

Part One

Salutation
* Mr. Mrs. Ms. Miss
* Male Female

Permanent Mailing Address
*Last Name:
*First Name: Second Name:
*Address:
Apartment #: *City: Province/State:
*Country:

Postal Code/ZIP:
 

Telephone / Fax
Country Code:
 
Home - Area/Region Code: Number:
Work - Area/Region Code: Number: Ext:
FAX - Area/Region Code: Number:
E-mail Address:
*Birth Date:
*Month: *Day: *Year:
*Country of Citizenship:
Canadian Social Insurance Number (if you have one):

*Preferred Language
English French
Other - Please specify:
 

*Basis for Admission Consideration
Secondary school graduate or equivalent
College/university studies
Please remember to mail or fax original transcripts or certified copies to the address shown above!
 

Additional Academic Information
Related work experience (please send résumé)


*Have you written the TOEFL (Test Of English as a Foreign Language)?

Yes
No
If you answered yes, please provide the following information:
*Date written: Month Day Year

*Your score:

*Type of TOEFL test taken: Paper-based Computer-based
 

*Have you written the IELTS (International English Language Testing System)?
Yes
No

If you answered yes, please provide the following information:

*Date written: Month: Day: Year:
*Your Score Listening: Reading: Writing:
Speaking: Overall Score:


Program Selection (in order of preference)

*1.
*Semester    
 
2.
Semester
 
3.
Semester
 


Authorization

I hereby certify that the above information is true and complete. I understand that any false or incomplete information submitted in support of my application may invalidate my application. I have read the Freedom of Information and Protection of Individual Privacy Statement (see below).

Freedom of Information and Protection of Individual Privacy Act: (read me...)

The information on this form is collected under the legal authority of the Ministry of Colleges and Universities Act, R.S.O. 1980, Chapter 272, S.S.,: R.R.O. 1980, Regulation 640. The information is used for administration and statistical purposes of Centennial College and/or the Ministries and Agencies of the Government of Ontario and the Government of Canada.

For further information, please contact:

ACTLAP EDUCATION CANADA

Agent of
Centennial College
2288-100 City Centre Drive
Mississauga, Ontario,
Canada L5B 3C8

*Applicant Signature: By clicking this checkbox, you are agreeing to the terms of the Freedom of Information and Protection of Individual Privacy Act as specified above.

Part Two

How did you first learn about Centennial College?
Canadian Embassy Educational resource in your home country
Education Fair Friend or Relative in Canada
The Internet Friend or Relative at home
Centennial Graduate Educational Publication:
Agent Other:

Who encouraged you to apply?
School Counsellor Parent
Agent Other:

Have you attended school or college in Canada before?
Yes No
If yes, please list the names and addresses of schools, and the programs and dates attended:
School
City
Program
Start Date
End Date

Future Education and Career Goals
If you are applying for English as a Second Language or English for Academic Purposes, do you plan to continue post-secondary study after your English course is completed?
Yes No
If yes, what programs interest you?

Do you plan to complete a diploma program and go on to university?
Yes No

Are you planning to work in Canada for one year after graduation (as permitted by Immigration Canada)?
Yes No
Part Three

If you have a contact person in Canada, please fill out the following section.
Information Release Pursuant to the Freedom of Information and Protection of Individual Privacy Act, I hereby authorize Centennial College to release any and all information related to any and all aspects of my application for admission, acceptance, fees or program of studies to the person whose name and address appears below. I certify that the person named is my selected representative and has my agreement to access and use this information to assist me to successfully register and access programs at Centennial College.

I authorize information release to my contact in Canada:

Applicant Signature: If you have provided information for a contact in Canada, please read the above terms and click the signature checkbox at left. By clicking this checkbox, you are agreeing to the terms of the Freedom of Information and Protection of Individual Privacy Act as specified above.
 
Contact's Name and Address (The information bellow have been auto filled for you - You do not need to change them unless you have extra information)
Contact's Name:
Contact's Address:
City:
Province:

Contact's Telephone, Fax and E-mail:
Phone: Area code: Number: -
 
Phone/Fax: Area code: Number: -
E-mail address:

Have you checked all your entries and verified that they are correct?

*Do not submit more than one application*

Note: We will contact you to begin the process of your application