Room 114, Wakpa Tower3737 Wascana Parkway Regina, SK Canada S4S 0A2 Phone: 306-585-4585 Fax: 306-585-4971

esl@uregina.ca www.uregina.ca/esl

To apply for the Academic ESL Program, please complete this form electronically and make sure you do the following: Pay the non-refundable application fee ($100 CAD), if you have NOT already applied to a credit program at the U of R. Pay the non-refundable tuition deposit ($400 CAD per semester), deducted from your total tuition amount. If you are a permanent resident in Canada, submit a copy of your Permanent Resident Card. If you are a Canadian citizen, submit a copy of your passport. If you are applying through an agent, or on behalf of someone else (e.g. a friend or relative), then complete and submit the

Declaration of Third Party Authorization form with this application form, which is available on our website: www.uregina.ca/esl If you have taken the IELTS Academic Test within the last 2 years, include a copy of the score report. If you have an overall

score of 6.0 with no band lower than 5.0, you are eligible to gain direct entry to Advanced EAP.If you have an overall score of 5.5 with no band lower than 5.0, you are eligible for direct entry to ESL 040 High Intermediate.Send the completed form, including a scanned copy or photocopy of your passport, to our address (indicated above).

PERSONAL INFORMATION

LAST/FAMILY NAME:

FIRST NAME:

GENDER: Male: Female:

U OF R STUDENT ID (If applicable): ID #:

DATE OF BIRTH: _____ Day/ _____ Month/ _____ Year

VALID PASSPORT #:

STATUS: International student: Canadian Citizen: Permanent resident: Country of Citizenship: __________________________________________________

SPONSORSHIP INFORMATION (If

you are a financially sponsored student, check off which program applies to you; if it is not listed, indicate it beside “Other” ):

Science without Borders/Canadian Bureau for International Education (CBIE):

Saudi Arabian Cultural Bureau (SACB):

Libyan-North American Scholarship Program: Kuwait Cultural Bureau:

Other: _______________________________________________________________

EMAIL ADDRESS:

PERMANENT ADDRESS (Inside or

outside Canada; this address will appear on your Letter of Acceptance):

Street: ________________________________________________________________ City:__________________________ Province/State: ___________________________ Country: ________________________________ Postal/Zip Code: ________________

MAILING ADDRESS (If different from address above):

Same as “PERMANENT ADDRESS” above: Street: ________________________________________________________________ City: _________________________ Province/State: ___________________________ Country: _________________________________ Postal/Zip Code: _______________

PHONE # (Local or international):

EMERGENCY CONTACT INFORMATION:

Name: ________________________________________________________________ Relationship to you (e.g. father, mother, etc.): ________________________________ Email: ________________________________________________________________ Phone #: ______________________________________________________________

ACADEMIC BACKGROUND : Have you attended an educational institution in the past year? Yes: No: If you checked off “Yes”, then please indicate the educational institution below: _____________________________________________________________________

PERMIT INFORMATION: Do you already have a study/work/visitor’s permit issued by the Government of

Canada? Yes: No:

CANADIAN VISA INFORMATION: Have you applied for your Canadian visa yet? Yes: No:

Have you obtained your Canadian visa yet? Yes: No:

HOW DID YOU FIND OUT ABOUT US?

Facebook: Friend/family member: Website: Agent: Other: _____________________________________________________________

V.11292017

AGENT INFORMATION

NAME OF AGENT:

NAME OF AGENCY:

FUTURE PLANS

Are you planning to study at the U of R after you successfully complete the ESL Program? Yes: No:

Have you already applied to the U of R? Yes: No:

If you answered “Yes” to any of these questions:

Check which program you are interested in:

Indicate which faculty you are interested in:

Undergrad: Grad: Faculty: _______________

ACADEMIC PROGRAM SEMESTER DATES AND TUITION

SEMESTER* TUITION (CAD)* (International, including sponsored, students)

TUITION (CAD)* (Canadian citizens / permanent residents)

FALL 2018 (Sep 4 – Nov 30) $4170 $3272WINTER 2019 (Jan 2 - Mar 29)

(* Semester dates and tuition fees are subject to change without notice.)

PAYMENT OPTIONS

METHOD OF PAYMENT: Visa: American Express: MasterCard: Wire Transfer: Bank Draft: Other:

IF YOU PAY WITH CREDIT CARD:

Credit card #:

Card holder name:

Security code (3 digit # on back of card): __ __ __

Date of expiry (month/year): /

Signature: _________________________________________ Date: _____________________

COST BREAKDOWN: Would you like your Letter of Acceptance mailed by courier ($100 CAD*) fee? Yes: No: (Acceptance Letters are mailed by regular post AND sent by email, unless you chose “Yes” above.)

i) If you indicated “Yes” to the above courier fee ($100 CAD*) = $ _________ii) $100 CAD* application fee** = $ _________ iii) $400 CAD* non-refundable tuition deposit per semester = $ _________

Total amount you are paying = $

(* Fees are subject to change without notice.) ( ** If you have already applied to an undergraduate or graduate program at the U of R AND have paid your $100 application fee, you do NOT need to pay the ESL application fee.)

I understand that admission to the ESL Program does not constitute admission to credit or degree programs at the University of Regina. I assume full responsibility for my financial obligation, medical coverage and other insurance plans.

Applicant signature: _____________________________________ Date: ___________________ Your official Acceptance Letter will be sent to you once we receive the tuition deposit and application fee, if applicable. In order to be eligible for a Canadian study permit, which serves as a Canadian student visa during your stay, the

Government of Canada may require that you apply for a minimum of 6 months (or 2 semesters) in the ESL Program. Pleaseconsult a Canadian visa office in your country to confirm the minimum length of time you are required to study in Canada.

Students with conditional admission, pending English proficiency, to an undergraduate or graduate program already meet theminimum program length, and therefore should apply for only one semester.

For more information about our Policies and Rules regarding fees, visit our website: www.uregina.ca/esl If you have any questions or concerns, please call 306.585.4585, or email esl@uregina.ca

Check off the semester(s) you are applying for:Winter 2019Fall 2018

$4170 $3272SPRING/SUMMER 2019 (May 1 - Jul 26) $4170 $3272

Spr/Sum 2019