Académique Documents
Professionnel Documents
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Personal Information
Legal First Name Legal Middle Name Legal Last Name Former Name (if Applicable)
Date of Birth (mm-dd-yyyy) Place of Birth (Country) First Language Country of Citizenship Citizenship Status in Canada
Male
Canadian Citizen Study Visa
Female
Permanent Resident
Last Educational Institution Attended: Program Name or Level Completed Complete/Incomplete Date Completed
Program
Name of Program (Application fees are non-refundable) Application Fee
100.00
Declaration and Student’s Signature
I hereby certify the information provided on this application for admission is true and complete in all respects. I also understand that any
misrepresentation on my part may result in cancellation of my admission or registered status. I agree, if admitted to a Faculty of Extension program
at the University of Alberta, to comply with the University regulations in the University of Alberta Calendar.
Date: Signature:
The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act for authorized purposes including application for admission,
registration, administration of records, scholarships and awards, student services, alumni relations and fundraising, and university planning and research. A student’s and alumni’s personal information may be disclosed to
academic and administrative units according to University policy, federal and provincial reporting requirements, data sharing agreements with student governance associations, and to contracted or public health care providers as
required. Questions concerning the collection, use or disposal of this information should be directed to: FOIPP Officer, Faculty of Extension, 10230 Jasper Ave NW, Edmonton, AB T5J 4P6. Phone 780.492.5047
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FACULTY OF EXTENSION
REGISTRATION OFFICE
Payment Information
Enclose the Non-Refundable Application Fee. Payment can be made by Visa, MasterCard, American Express,
Discovery card, Indent, Invoice (include LOA or PO), Cash, Cheque, Money Order (made payable to the
University of Alberta).
I’ve included my Non-refundable payment of:
Are you a University of Alberta staff member?
$100 – for Faculty of Extension Citations and Certificates � yes � no If yes, U of A staff members are exempt from
CHECK PAYMENT METHOD: the $100.00 application fee.
CASH MONEY ORDER** CHEQUE** HRDF INDENT *Your personal e-mail address will be used to communicate to you until you
INVOICE - If employer is to be invoiced, please include a Letter of Authorization (LOA) on company are assigned a University of Alberta e-mail account. Subsequent
letterhead, or an authorized Purchase Order (PO) signed by signing authority (not student). communications will be sent to your U of A e-mail address. It is your
responsibility to check your U of A email frequently.
CREDIT CARD: Attach CC Receipt E-mail Receipt: **Make cheques or money orders payable to the University of Alberta
Name on Card:
FOR OFFICE USE ONLY: RECEIPT #:
Credit Card Number Expiry (mm-yy)
Checklist
Non-refundable Application Fee is included with application. U of A staff members are exempt.
The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act for authorized purposes including application for admission,
registration, administration of records, scholarships and awards, student services, alumni relations and fundraising, and university planning and research. A student’s and alumni’s personal information may be disclosed to
academic and administrative units according to University policy, federal and provincial reporting requirements, data sharing agreements with student governance associations, and to contracted or public health care providers as
required. Questions concerning the collection, use or disposal of this information should be directed to: FOIPP Officer, Faculty of Extension, 10230 Jasper Ave NW, Edmonton, AB T5J 4P6. Phone 780.492.5047
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