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APPLICATION FOR ADMISSION FORM:

1. PROGRAM APPLIED FOR:


2. SECOND OPTION:


3. DELIEVERY METHOD:

ON-LINE ACCESS _______ DISTANCE LEARNING ______

4. TDLI STUDENT NUMBER: _______________________

5. PERSONAL AND CONTACT INFORMATION:

6. FIRST NAME:


7. MIDDLE NAME OR INITIAL:


8. LAST NAME:


9. FULL COMPLETE MAILING ADDRESS:



HOME PHONE: __________________________________

BUSINESS PHONE: _______________________________

CELLULAR PHONE: ______________________________

E-MAIL: _______________________________________

FAX: __________________________________________

WEB SITE URL: _________________________________

FIRST LANGUAGE: ______________________________

SECOND LANGUAGE: ____________________________

CITIZENSHIP: ___________________________________

DATE OF BIRTH: ________________________________

PASSWORD: ____________________________________
(Used for telephone confirmation of student for disclosure.)

DECLARATION OF THE APPLICANT:

The information and collection on this form is collected under the authority of the Post-Secondary Learning Act, The Freedom of Information and Protection Act, The Statistics Act of Canada, and the Taxation Act of Canada.

I understand that all documentation submitted in support of this or any other subsequent application for admission, financial award, or any appeal or petition becomes the property of Trafalgar Distance Learning Institute.

The information will become part of my student record and will be disclosed to the relevant TDLI departments and or staff for the purposes of administration of policies, procedures, programs, services, registration, tax receipts, scholarships and awards, graduation, follow-up educational information, research, and alumni programming and or follow up.

In addition, I authorize TDLI to disclose or request information from the federal or provincial governments to meet reporting requirements and to determine eligibility for services of this information, contact the office of the registrar at TDLI Suite 203, 4909 B 48th Street, Red Deer, Alberta, Canada, T3E 7M7. Fax: 1 403 770 8120.

I certify that I have read and understood that I have read, understood, and completed all this information in this application and institutes Prospectus and accompanying information.

I certify that all the statements I have made to my student services advisor and or on this application are true and as true as they can be to the best of my knowledge; and complete in all respects.

I understand that any misrepresentation, falsification of documentation, or withholding requested information are serious offences to this academic institution which may result in cancellation of my admission and or registration, and or dismissal outright from the TDLI.

If and when I am admitted, I agree to be bound by the rules and regulations in existence or as amended from time to time in the by-laws of the institution, and or the board of governors, and or your student services advisor and or the President and CEO of the Trafalgar Distance Learning Institution.

Applicants Signature: _______________________________

Applicants Printed Name: ____________________________

Date: ______________________________________________

Program Path: ______________________________________

Check if non-refundable application fee is enclosed: ______

End of Application Form.

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