ONLINE POWER ENGINEERING PROGRAM REGISTRATION FORM Email Completed Form To: [email protected] STUDENT ID PERSONAL DATA LEGAL FIRST NAME LEGAL LAST NAME

ONLINE POWER ENGINEERING PROGRAM REGISTRATION FORM Email Completed Form To: Registrar@Keyano.Ca STUDENT ID PERSONAL DATA LEGAL FIRST NAME LEGAL LAST NAME

ONLINE POWER ENGINEERING PROGRAM REGISTRATION FORM Email completed form to: [email protected] STUDENT ID PERSONAL DATA LEGAL FIRST NAME LEGAL LAST NAME

SOCIAL INSURANCE NUMBER* EMAIL ALBERTA STUDENT NUMBER

PHONE # DATE OF BIRTH GENDER Male Female Undefined Unspecified     ADDRESS CITY PROVINCE POSTAL CODE

*SIN is required by the Canada Revenue Agency for T2202 tax receipts, without your SIN we cannot provide a tax receipt.

EMERGENCY CONTACT / RELATIONSHIP EMERGENCY CONTACT NUMBER ARE YOU A PERSON WITH A ACTIVITY DURING PREVIOUS 12 DISABILITY? (Optional) MONTHS  Yes  No  Student MARITAL STATUS FIRST LANGUAGE SPOKEN CITIZENSHIP STATUS COUNTRY OF CITIZENSHIP IF  Labour Force YOU ARE NOT A CANADIAN  Single/Never Married  English  Canadian Citizen CITIZEN  Other: ______ Married/Cohabitant  French  Permanent Resident  Other (Widow/Divorce)  Other (specify)  Student VISA  DATE OF ENTRY INTO CANADA LOCATION OF PREVIOUS ACTIVITY ______Other (specify) ______MONTH YEAR  Alberta  Other Province  Outside Canada IF YOU WISH TO DECLARE THAT YOU ARE AN ABORIGINAL PERSON, PLEASE SPECIFY:  Status Indian/First Nations  Non Status Indian/First Nations  Métis  Inuit

Alberta Advanced Education and Technology is collecting this personal information pursuant to section 33(c) of the FOIP Act as the information relates directly to and is necessary to meet its mandate and responsibilities to measure system effectiveness over time and develop policies, programs and services to improve Aboriginal learner success. For further information or if you have questions regarding the collection activity, please contact the Office of the Director, Business Operations and Reporting, Post-secondary Excellence Division, Alberta Advanced Education and Technology, 10155-102 Street, Edmonton AB, T5J 4L5, (780) 427-7145 or Keyano College, Office of the Registrar.

EDUCATION RECORD: ARE YOU IN HIGH HS DIPLOMA LAST SCHOOL ATTENDED OR CURRENTLY LAST YEAR LENGTH OF TIME SCHOOL? RECEIVED/EXPECTED? ATTENDING ATTENDED ATTENDED (YRS.)

 Yes  No  Yes  No

LEVEL ACHIEVED (CERTIFICATE, DIPLOMA, DEGREE) CITY PROVINCE/COUNTRY PROGRAM/FACULTY

APPLICANT’S SIGNATURE DATE

METHOD OF PAYMENT CREDIT CARD NUMBER EXPIRATION DATE

CARD ISSUED TO SIGNATURE

 Phoned In 4120000 - 41210 GST #R107566218

The personal information requested on this form is collected under the authority of section 65 of the Post-Secondary Learning Act and section 33© of Alberta’s Freedom of Information and Protection of Privacy Act and will be used for the purpose of admission, registration, issuing income tax receipts, scholarships and award, convocation, sending education information, library services, emergency notification, and for college research and planning. Certain personal information will also be disclosed to Statistics Canada to comply with the Statistics Act; Alberta Advanced Education to meet reporting requirements; Alberta Human Services for determining and monitoring student eligibility for their services; work experience and practicum sites to set up appropriate placements; Students’ Association for the purposes of membership and information sharing; Syncrude Sport & Wellness Centre for the purposes of membership, Student Academic Support Services for the purposes continuous improvement of student academic success. For information about the collection and use of this information, contact the Registrar. Keyano College Office of the Registrar | 8115 Franklin Avenue, Fort McMurray AB T9H 2H7 Toll Free 1.800.251.1408 | Telephone 780.791.4801 | E-Mail [email protected] www.keyano.ca/forms REVISED 2021/07/01

ONLINE POWER ENGINEERING PROGRAM REGISTRATION FORM

Application Fee of $54 charged to all NEW students,  Or students returning after an absence of one academic year or more.

Tuition Students’ SA Building Campus Technology Student to be registered Total in: Association Fund Recreation Fee Fee PE 4th Class NEW  (6 months) $591.50 $91.00 $14.56 $55.00 $75.00 $827.06 PELM 4100 Term/Section: Start date: End date:

PELM 4200 Term/Section: Start date: End date: PE 4th Class NEW  (6 months) $591.50 $91.00 $14.56 $55.00 $75.00 $827.06 PELM 4300 Term/Section: Start date: End date:

PELM 4400 Term/Section: Start date: End date:

4th Class Power Engineering certificate provided PE 3rd Class Part ‘A’  (6 months) $664.00 $91.00 $14.56 $55.00 $75.00 $899.56 PELM 3100 Term/Section: Start date: End date:

PELM 3200 Term/Section: Start date: End date: PE 3rd Class Part ‘B’  (6 months) $664.00 $91.00 $14.56 $55.00 $75.00 $899.56 PELM 3300 Term/Section: Start date: End date:

PELM 3400 Term/Section: Start date: End date:

OFFICE OF THE REGISTRAR CONTRACT # CWA # COST CENTRE PO # / INVOICE COMPANY

PROCESSED BY AUTHORIZATION # COMPANY CONTACT

OFFICE OF THE REGISTRAR SIGNATURE DATE

OFFICE OF THE REGISTRAR  Application entered  Payment Received: Initial:  Set Up Academic Tab  Copy of PR Card  Registration Processed: Initial:  Email student schedule & statement  Assess tuition & set up application fee