APPLICATION FORM Science Without Borders Program (SWB) Personal Information Family name: Date of Birth (mm/dd/yy): _____/____/_____

City of Birth & Country of citizenship: Given name(s): Gender: First language: Second language: Passport number: Expiration date (mm/dd/yy): Fathers Given and Maiden name: _____/____/_____ Your contact details in Brazil: Address: Phone (day): Mobile: Email address: Emergency contact: Name: Address: Phone: Relationship to you: Mothers Given and Maiden name: Male Female

Marital status: Single Married

Name of Spouse, if applicable: Family Name:

Given name(s):

Telephone:

Email:

Program choice(s) What program are you applying for? 1) 2) 3)

Current Institution Name of institution in Brazil:

Address:

From (month/year): _____/_____ to ______/______ Recent year of study:

Certificate, diploma, degree obtained or expected:

Education Background Degree or Qualification Example Degree in psychology Institutes Federal IF Sao Paulo Degree/Diploma awarded Yes Years attended 2010-2012 Language of instruction Portuguese

Language Test Date of IELTS or TOEFL test: (mm/dd/yy): _____/____/_____ Results (attached certified copy):

Note: Prior to coming to Canada for ESL, the minimum score for the Internet-based TOEFL score is 70. The applicant must have achieved this minimum prior to coming to Canada to study. The IELTS minimum score prior to coming to Canada is 6.0.

Accommodation Expectations The following questions will help in organizing your placement in a college. Do you prefer living in a city or a smaller community? City Smaller community Do you want to live in a college residence, hotel, individual apartment or family homestay? College residence Hotel Individual apartment Family homestay Do you have a medical condition that requires special needs? Yes No Specify:

Do you have any allergies (foods, pets, etc.)? Yes No Specify:

Do you require a host with similar religious beliefs? Yes No Specify:

Will you live in a house with a cat and/or dog? Yes No Specify:

Will you live in a house with children and/or teenagers? Yes No Do you smoke Yes

No

What are your hobbies and interests?

SUPPORTING DOCUMENTS

1. Original transcripts of certificate in Portuguese preferred if available in English. Please send scanned documents to mabdelwahab@accc.ca and/or farnouldlalonde@accc.ca by April 17th, 2012. 2. Proof of citizenship. A copy of your valid and current passport identity page, including personal information. Please send the scanned pages to mabdelwahab@accc.ca and/or farnould-lalonde@accc.ca by April 17th, 2012. 3. Statement of grades/transcript in Portuguese from your institution. Please send the scanned pages to mabdelwahab@accc.ca and/or farnould-lalonde@accc.ca by April 17th, 2012. 4. Program descriptor and classes descriptors, if available. Please send the scanned pages to mabdelwahab@accc.ca and/or farnould-lalonde@accc.ca by April 17th, 2012. 5. If available, Curriculum Vitae. The CV should include all relevant and pertinent information concerning the academic career. The candidate is encouraged to include academic presentations, awards, relevant work, etc. Please send the scanned pages to mabdelwahab@accc.ca and/or farnould-lalonde@accc.ca by April 17th, 2012.

For more information, you can reach Mehdi Abdelwahab at mabdelwahab@accc.ca or by phone at 001-613-746-2222 ext. 3161.