English Language Diagnostic Questionnaire

Declaration of Bilingual Competence: English Language

Students whose primary, first language, native language or dominant language is English, who consider themselves fully bilingual, and who are applying for a program in administration, cheminement bilingue, linguistics, English, translation or in teaching English as a second language may complete and return this form, with their application, if they wish to be exempted from the English placement test.

Program applied for: Baccalauréat en administration, cheminement bilingue (7364) ( ) Majeure en langue et linguistique (6632) ( ) Certificat inter-universitaire en langue anglaise (4425) Certificat en traduction (6295) ( ) Programme court de traduction en anglais (0458) ( ) Programme court de traduction en français (0658) ( ) Programme court en enseignement de l'anglais langue seconde (0502) ( )

______Section A: General information

Last name: ______Given name(s):______

Birthdate: D: ____ M: ____ Y: ____ Student I.D. #:______or New student: ( )

Address:______City:______

Postal code:______Country______

Telephone: Home: ( ) ______Office: ( ) ______

E-mail:______

______Section B: Education

Previous courses in English-speaking establishments (latest official diploma and transcripts must be included) Year Level/grade Most recent Province or academic grades country

English elementary/primary school

English secondary school

English post- secondary/university Section C: College or university level courses in the English

College or university English language courses (transcripts and course descriptions must be included)

Course title Year Level/grade Most recent Province or academic grades country ______

______

Section D: Other experiences in English

Other English language experience (please provide details and include your curriculum vitae)

( ) Work experience: ( ) Travel: ( ) Family: ( ) Live(d) in an English-speaking community: ( ) Courses (year, duration, name of institution):

Additional comments (experience in translation, teaching, etc.):

______

Section E: Declaration and signature

As a bilingual student, I request to be exempted from the English placement test.

Signature: ______Date:______

Space reserved for UER Sciences Humaines, Lettres et Communications

The candidate is exempted from the English placement test ( ) The candidate must take the English placement test ( ) Commentary: ______

Authorized signature: ______Date: ______