Birthday (D/M/Y)

Treaty No. Social Insurance No.

Marital Status Select One Single Married Common Law Separated Divorced Widowed

Address

Address2

City Province/State Postal Code

e-mail Address

Home Phone Fax No.

Business Phone Cellular Phone

Are you currently employed? Yes No

Income source and amount per year:

Have you received E.I.? Yes No

B. Previous and Current Education:

High School attended:

City Province/State Postal Code

Dates Attended: From: Month Select January February March April May June July August September October November December Year To: Month Select January February March April May June July August September October November December Year

Diploma Received:YesNo Highest Grade completed:

University, College, Technical Institute:

City Province/State Postal Code

Dates Attended: From:Month Select January February March April May June July August September October November December Year To: Month Select January February March April May June July August September October November December Year

Completed: Yes No

If Completed:Degree, Diploma, or Certificate obtained:

C. MARITAL/FAMILY INFORMATION

Marital Status: Select One Single Married Common Law Divorced Separated Widowed

Name of Spouse:

Address:

City Province/State Postal Code

Treaty Number of Spouse:

Member of Which First Nation:

Employment Status of Spouse: Select One Employed Self-employed Unemployed Attending School

If Spouse is employed: Where:

Address:

City Province/State Postal Code

Annual Income:

If Spouse is unemployed source of income:

DEPENDANTS:

Name: Birthdate: m/d/y

Name: Birthdate: m/d/y

Name: Birthdate: m/d/y

Name: Birthdate: m/d/y

Name: Birthdate: m/d/y

Name: Birthdate: m/d/y

Are they currently residing with you?Yes No

Do you or your spouse receive any income for their support (child tax benefits, child support/maintenance/trust-fund)Yes No

If yes, amount per month?

D. ASSISTANCE REQUESTED:

Have you been accepted to a post-secondary institution? Yes Unknown at this time

If yes, please mail a copy of the letter of acceptance.

Institution:

Program/Faculty/College:

Location: City: Province:

Major/Specialization:

Length of Program:

Program: Select One Regular Co-op Study Attendance: Select One Full-time Part-time

Expected completion date:

Practicum? YesNo If yes, when and how long:

Assistance requested: Select all requests Living Allowance Tuition Books

Assistance for this academic term to commence:

Month Select January February March April May June July August September October November December Year Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 To: Month Select January February March April May June July August September October November December Year Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Will you be applying for a student loan? Yes No

E. CAREER PLANNING:

1. What factors influenced your decision to attend post-secondary education?

2. Have you completed a career study?Yes No

3. Who or what resources have you checked with regard to your career path?

4. What are your long-term goals related to post-secondary education?

F.COMPLETE IF YOU HAVE PREVIOUSLY ACCESSED POST-SECONDARY EDUCATION FUNDING FROM ANY SOURCE INCLUDING MUSKEG LAKE POST SCHOOL PROGRAM.

5. What source(s) of funding have you previously accessed for post-secondary education?

6. For what education/training program?

7. Were you successful in completing the requirements of the course? YesNo

If No go to question 8

8. What steps have you taken to ensure your successfulcompletion of this training/education?

I authorize the Muskeg Lake Post School Program to access information concerning my academic records at the institution I am attending.  I accept responsibility for satisfying the academic requirement sof the institution and managing the education assistance funds to the best of my ability.  I will complete a student monitoring report/progress report/cumulative record signed by an authorized program/academic advisor at the institution of study and will forward a copy to the Muskeg Lake Post School Program before the term ends. I will submit a copy of final marks at the end of each term and a declaration of full-time attendance each month.