International student application

Personal Details
Male Female Mr. Mrs. Miss Ms.

Surname (family name) Given (first) name

Nationality Date of birth

( DAY / M O NT H / Y E A R )

Student’s mailing address

Street name and number Apt.

City/prefecture Country Postal code

Home telephone number Alternate number

Fax number E-mail

Program choice

Priority Program title Code Start date (month/year)

English as a Second Language/ English for Academic Purposes

September Late October January March May July

Academic record

Transcripts enclosed? Yes No To Follow Funds Enclosed? $100 CDN application fee (see Page 2 for payments)

Last school attended

Address City Country

Highest level passed TOEFL score (if available) Other English assessment

In your schooling, was English the main language of instruction? Yes No If yes, how many years?
In case of emergency – contact person

Surname (family name) Given (first) name

Street name and number Apt.

City/prefecture Country Postal code

Home telephone number Alternate number

Fax number E-mail

Accommodation

I will not need help with accommodation I would like information on homestay

I would like to stay in residence I will require airport pickup

Feedback

How did you hear about Durham College?

Why did you apply?

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 Durham College of any offered place, and that this
withdrawal may also take place at any time during my enrolment. I authorize Durham College to obtain any details relating to my
academic record at the institution(s) listed on reverse in order to evaluate my application.

Applicant signature Date

Please mail this completed application, including secondary school transcripts and the $100 CDN application fee, to:
Durham College International office
2000 Simcoe Street North, Oshawa, Ontario, Canada L1H 7K4
Phone: 905.721.2000 ext. 2355 | Fax: 905.721.3372 | E-mail: international@durhamcollege.ca

Payment may be made by certified cheque (payable to Durham College),

money order, MasterCard, Visa and/or electronic bank transfer.

Card name Name of cardholder

Card number Expiry date

Cardholder signature

Agency information (educational/recruitment service if applicable)

Agency name

City Country

In accordance with section 39(2) of the Freedom of Information and Protection of Privacy Act, you are advised that the personal information collected on this form is
collected under the authority of the Ministry of Colleges and Universities Act, R.S.O., 1990 and Regulation 770. It will be used by Durham College personnel only for
relevant College activities and may be used for statistical and administrative reporting purposes of the College. No personal information will be made available to third parties.