AU Grouped Study General Application Form

AU Programs and Courses onsite at Athabasca University or . New and inactive students must complete this form for admission to Athabasca University.

Athabasca University Student ID Number 1 I am taking courses on site at AU-Edmonton 1 I am taking courses on site at AU-Calgary Student Number (ASN) General Information (please print clearly)

Name: ______LAST ______FIRST MIDDLE Telephone (Primary): ______( )

Former Name: ______LAST FIRST MIDDLE Telephone (Secondary): ______( ) (if applicable) Email Address: Mailing Address: ______

Date of Birth: City/Town: ______DAY MONTH YEAR

Prov./State: ______

Country: ______

Postal/ Zip Code: ______

Athabasca University gathers the following information on behalf of the institution and/or Alberta Advanced Education

Gender: Male Female Unspecified

Are you a person with a Yes disability? (optional) No

Are you an Aboriginal person 1 Yes If yes: First Nation Status Indian First Nation Non-Status Indian residing in ? (optional) No Métis Inuit

Citizenship: Canadian Other (country of citizenship): ______If other: Study Authorization/ Permit Permanent Resident/Landed Immigrant

First Language: English French Other (indicate language): ______

Level of education completed High School Diploma College, Vocational School, or Technical Institute Diploma/Certificate (check all that apply): Some University University Degree

Educational History (please print clearly)

Please list ALL post-secondary institutions, including Athabasca University, in order of attendance. If you need more space please add a separate sheet and attach it to this form. Credential Shaded area for office use received? only Institution City/Town Years attended Name of Credential (yes/no) to

to

To arrange for an AU evaluation of your transcripts for transfer credit towards an AU degree, please arrange with the institution(s) above to send your official transcript(s) to: Office of the Registrar, Athabasca University, 1 University Drive, Athabasca, AB, T9S 3A3. Admission to Athabasca University – Please make a selection Athabasca University Student ID Number I am a new AU student. Enclosed is the one-time, non-refundable General Application Fee.

I wish to enrol:

As a Program Student in the University's: ______(Refer to the Athabasca University Calendar for a list of available programs: http://calendar.athabascau.ca/undergrad/current/index.php

1 As a Non-Program Student.

Athabasca University Fee Payment

You may use a credit card, money order, or cheque to pay Athabasca University fees. Please do not send cash in the mail. Post-dated cheques are not accepted. Do not send confidential information via email. Email messages are not secure.

I am paying my Athabasca University fees in the following manner:

1 Cheque / Money Order – payable to Athabasca University – attached to this form.

Charge to my credit card: VISA MasterCard AMERICAN EXPRESS

Card number: Expiry date: _____ / _____

‡ For current fee information, refer to an Athabasca University Calendar or online at calendar.athabascau.ca/undergrad/current/fees-refunds/fees.php

Your signature below means that: You agree to: Abide by the rules and regulations of Athabasca University as outlined in the online Calendar, and as they may be amended. You certify that the information you have provided on this form is true and complete in all respects and that no relevant information has been withheld. You agree that Athabasca University retains the right to nullify your application if the information provided is false or incomplete. Falsification and misrepresentation of credentials or supporting documents is considered an academic offence and penalties may be imposed as per Athabasca University's Student Code of Conduct and Right to Appeals Regulations. http://calendar.athabascau.ca/undergrad/current/student-code/index.php You have read the following text: The personal information collected on this form, and any other personal information collected and maintained as part of a student’s record, will be used for the purposes of admission, registration, issuing income tax receipts, scholarships and awards, convocating, sending educational information, for university research and planning, and for the purpose of processing payment, if applicable. Certain personal information will also be disclosed to Statistics Canada (as required by the Statistics Act [Canada]), Advanced Education to meet reporting requirements, and by agreement, to the Students’ Union and Alumni Relations for the purposes of membership, fee collection, and contacting students. This information is collected under the authority of the Post-secondary Learning Act, 2003, which mandates the programs and services offered by Athabasca University, and Section 33(c) of Alberta's Freedom of Information and Protection of Privacy Act. The information will be protected by the provision of Alberta's Freedom of Information and Protection of Privacy Act. If you have any questions about the collection and use of this information, contact the Coordinator, Enrolment, Records, and Examination Services, Athabasca University, 1 University Drive, Athabasca, Alberta T9S 3A3. Phone: 800.788.9041. Advanced Education is collecting this personal information pursuant to Section 33(C) of the Alberta Freedom of Information and Protection of Privacy (FOIP) Act as the information relates directly to and is necessary to meet its mandate and responsibilities to measure system efficiencies and develop policies, program, and services to improve Aboriginal learner success, in addition to other legislation applicable to the educational institution. For further information, or if you have questions regarding the collection activity, please contact the Director, Aboriginal Policy, Policy Sector, Information and Strategic Services Division, Advanced Education, 10155 102 Street, Edmonton, Alberta, T5J 4L5. Phone: 780-427-8501. You authorize: Athabasca University and your institution to share information regarding your FULL RECORD for the purpose of admission to a program of studies, for scholarships and bursaries, to facilitate course registration and program administration, to evaluate and assign appropriate credit for previous post-secondary education, and for statistical purposes. NOTE: This waiver is in effect as long as you maintain continuous status in the program.

Signature: ______Date: ______

Please submit this form (and fees) to: Enrolment Services Office of the Registrar Athabasca University 1 University Drive Athabasca, AB T9S 3A3 Tel: 1-800-788-9041 Email: [email protected]*

* Note: this email address is provided to obtain information only. Students should not send personal or financial information via email as it is not a secure method of communication.