APPLICATION FOR UNDERGRADUATE U OF R STUDENT I.D.

NUMBER

RE-ADMISSION / FACULTY TRANSFER

SEMESTER FOR WHICH TRANSFER SHOULD BE EFFECTIVE
On-Campus
FALL (Sept.–Dec.) WINTER (Jan.–April) SPRING (May–August) YEAR
Off-Campus
PERSONAL INFORMATION AND CURRENT MAILING ADDRESS
Last/Family Name First Name Middle Name
Mr. Ms. Miss Mrs. Other _________

Preferred Name (if different than First) Previous Name (if applicable) Phone: Business Ext.

( )
Address – Apt #, Street or Box # Fax □ Home □ Work

( )
City/Town Prov./Country E-mail

Postal Code Phone: Home Emergency Contact Name and Phone Number

( )
Social Insurance Number (Optional) Birthdate (eg. 06-Jan-1980)

DD/MON/YEAR
Citizenship
Canadian Permanent Student Visa
Citizen Resident (Student Authorization) Other: _____________________________
(Landed Immigrant) Country of Citizenship: _____________________ Country of Citizenship: _____________________

LAST OR CURRENT ATTENDANCE AT THE UNIVERSITY OF REGINA

Campus (U of R or Federated College) Faculty Degree/Certificate/Program Last Semester Attended

ALL OTHER POST-SECONDARY INSTITUTIONS ATTENDED (if any)

Post-Secondary Institution City/Province/Country Program/Degree Degree Received From: Mon/Year To: Mon/Year

Were you required to discontinue studies at any of these post-secondary institutions? YES NO
If YES, give name of institution and date: __________________________________________________________________
RE-ADMIT AND/OR TRANSFER TO
Campus (U of R or Federated College) Faculty Degree/Certificate/Program Major

BY ENROLLING IN COURSES AT THE UNIVERSITY OF REGINA, STUDENTS CONSENT TO THE COLLECTION, USE, AND DISCLOSURE OF PERSONAL
INFORMATION AS DESCRIBED IN THE SECTION OF THE UNDERGRADUATE CALENDAR ON FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY. FOR
FURTHER DETAILS, CONTACT THE REGISTRAR'S OFFICE AT (306) 585-4176. BY SIGNING THIS FORM, YOU ARE CERTIFYING THAT ALL QUESTIONS HAVE
BEEN ANSWERED IN FULL AND THAT THE INFORMATION PROVIDED IS CORRECT AND COMPLETE. YOU AGREE TO ABIDE BY UNIVERSITY OF REGINA RULES
AND REGULATIONS AND UNDERSTAND THAT OTHERWISE YOUR RE-ADMISSION TO OR REGISTRATION IN THIS UNIVERSITY MAY BE REVOKED.

_______________________________________________________ ____________________________________
APPLICANT’S SIGNATURE DATE

OFFICE USE ONLY – do not write below this line

Date Completed: Admit Code: Decision Code:

Comments:
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Distribution: White – Registrar Yellow - College (Faculty) To Pink - College (Faculty) From 10M – May 03