Mississauga Campus

QUESTIONS? International StudentWrite, Application call, fax or email to Formus. (Mississauga Campus) By Regular Mail Evergreen College, Mississauga Personal Information Campus

Gender: Male Female Date of Birth ( Day / Month1140 Burnhamthorpe/ Year): Road / / Wes, suite 201, Mississauga, Ontario L5C 4E9 Last (Family) Name: First (Given) Name: By Phone / Fax / Email Tel.: 1 (905) 566 0507 Full Name in Mother Language: Country of Residence: Fax: 1 (905) 566 4538 Nationality: Passport Number (if applicable): [email protected]

Permanent Address In Home Country

Street Name and Apartment Number (if applicable):

City: Province / State & Country: Postal Code:

Home Phone Number: Fax Number: Email:

Mailing Address If Different From Above

Home Phone Number: Fax Number: Email:

Emergency Contact

Last (Family) Name: First (Given) Name:

Relationship to You: Language Spoken:

Home Phone Number: Alternative Phone Number: Email:

How Did You Know About Evergreen College?

Agent Our Website Internet Newspaper / Magazine Relative / Friend

If from an Agent, please specify the name: Other:

Program Selection

Program Priority Program Title Start Date (Day/Month/Year)

1st Choice

2nd Choice

3rd Choice

Do you need Homestay Program? Yes No Do you need Airport Pick-Up? Yes No

Did you enclose the required funds? Yes No Yes No Yes No Cdn $200.00 Application Fee (non refundable) Yes No Yes No

Cdn $ 150.00 Homestay Placement (optional)

Cdn $ 100.00 Airport Pick-Up (optional) Medical Insurance Approx. Cdn $ 2.00 / Day (optional)

Did you enclose the required documents? Yes No Translated and notarized transcripts from highest level of Yes No education Yes No

Wondelic,TOEFL or IELTS test report (if applicable)

Payment Information

Payment can be made by Bank Draft, Certified Cheque, Credit Card, (Visa, Master Card, American Express) or Bank Transfer.

By Credit Card

Credit Card Information: Visa Master Card American Express

Card Number: Expiration Date (MM/YY): /

Cardholder’s Name (as it CVC: appears in your card):

Signature:

Bank Transfer Information

Beneficiary Bank: TD Canada Trust Bank Bank Account No.: 5223167 Bank No.: 004 Transit No.: 18682 Swift Code: TDOMCATTTOR

Bank Address: 1177 Central Parkway West, Mississauga, L5C 4P3, Ontario, Canada. Tel: 1.905.896.3188 Fax: 1.905.896.3911

DECLARATION I 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 and result in the withdrawal by Evergreen College of an offered seat at any time during my enrolment.

Applicant’s Name:

Applicant’s Signature: ______Date:

Mississauga Campus 1140 Burnhamthorpe Road Wes, suite 201, Mississauga, Ontario L5C 4E9 Canada Tel: 1.905.566.0507 Fax: 1.905.566.4538