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Student Application Form

Pre-Medical / Post-Baccalaureate / Prerequisite Program

|Personal Information |

|Gender: | Male Female |Date of Birth ( Day / Month / Year): |   /    /      |

|Last (Family) Name: |      |First (Given) Name: |      |

|Full Name in Mother Language: |      |Country of Residence: |      |

|Nationality: |      |Passport Number (if applicable): |      |

|Permanent Address In Home Country |

|Street Name and Apartment Number (if applicable): |      |

|City: |      |Province / State & Country: |      |Postal/Zip Code: |      |

|Home Phone Number: |      |Mobile Number: |      |Email: |      |

|Mailing Address If Different From Above |

|Street Name and Apartment Number (if applicable): |      |

|City: |      |Province / State & Country: |      |Postal/Zip Code: |      |

|Home Phone Number: |      |Mobile Number: |      |Email: |      |

|Emergency Contact |

|Last (Family) Name: |      |First (Given) Name: |      |

|Relationship to You: |      |Language Spoken: |      |

|Street Name and Apartment Number (if applicable): |      |

|City: |      |Province / State & Country: |      |Postal/Zip Code: |      |

|Home Phone Number: |      |Alternative Phone Number: |      |Email: |      |

|Program Selection |

|Program |Start Date (Day/Month/Year) |

| Pre-Medical |      |

| Post-Baccalaureate |      |

| Perquisite |      |

|Academic Background |

|From Year |To Year |Name of School |GPA |

| | | | |

| | | | |

| | | | |

|Have you ever withdrawn or dropped out of an educational institution? |

|No Yes If yes, Please state why? |

|TOEFL Score : |IELTS Score : |

|Status In Canada |

| Canadian Citizen Permanent Resident Study Permit / Visa |

|Do you have any medical condition(s) (physical or psychological) for which you need special accommodation in class, labs, or campus? No Yes |

|If yes please list your condition(s): |

| |

|How Did You Know About Our Premedical Program? |

| Drs. Silverman | Evergreen Website | MEA Website | Social Media | Newspaper / Magazine |

| Internet Search |Workshop | Fair _________ | Poster | Relative / Friend |

|If from an Agent, please specify the name: |      |Other: |      |

|Do you need Homestay Program? | Yes No |

|Do you need Airport Pick-Up? | Yes No |

|Did you enclose the required funds? | |

|Cdn $200.00 Pre-Medical Application Fee (non-refundable) |Yes No |

|Cdn $100.00 Post-Baccalaureate or Prerequisite Application Fee (non-refundable) |Yes No |

|Cdn $ 150.00 Homestay Placement (optional) |Yes No |

|Cdn $ 100.00 Airport Pick-Up (optional) |Yes No |

|Medical Insurance Approx. Cdn $ 2.00 / Day (optional) |Yes No |

|Did you enclose the required documents? | Yes No |

|Translated and notarized transcripts from highest level of education |Yes No |

|Wondelic,TOEFL or IELTS test report (if applicable) |Yes No |

|Payment Information |

|Online payment system where you can pay your tuition online with a valid credit card (Visa or MasterCard) or via a wire transfer for international |

|students. For domestic students, they can also pay us by cheque / money order, interact or cash. |

|International Payments can be made to Evergreen College via |

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|Using this portal, it is important to ensure that all your details are correct and are the same as the details provided when you enrolled with |

|Evergreen College. You will also need your Student ID Number available as this will be used as your payment invoice reference number. |

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|Please be advised that payments made online through the online payment system can take up to 4 business days to process. Another thing to note is the |

|time difference between where you are located and our Head Office Campus for processing reasons. |

|Documents needed to apply checklist |

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|Applicants will be evaluated based on their academic excellence, interview, personal statement, letters of reference, and commitment to extracurricular|

|activities. We request the following documents in English or French. If the documents are in another language please send a copy and certified |

|authorized English translation: |

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|Proof of citizenship status (Canadian Driver’s License, Passport, Citizenship card for domestic students) or passport and Study Permit / Visa |

|documents for international students ( Study Permit / Visa should be submitted after acceptance) in color scanned copies |

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|Official high school or university transcripts issued to us and sent directly to our address |

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|Copy of Ontario Secondary School Diploma (or equivalent for out of province or international students), university degree, college diploma (please |

|present the original diploma during registration) |

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|Resume |

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|Personal statement on your motivation to become a doctor and your qualifications (maximum 500 words) |

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|Two letters of recommendation on official letterhead sent directly to our e-mail by referee or by mail to our address and addressed to Dr. Lorelei |

|Silverman. Examples of referees: a teacher, a health care professional, and a professional who has supervised you either in your work or |

|in volunteering activities who can comment on your leadership, interpersonal, teamwork, and communication skills, ethics and moral standards, etc. |

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|Completed application form |

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|Proof of official English proficiency test results for international students (acceptable test score for TOEFL is 78 and for IELTS is 6) |

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|Non-refundable application fee |

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|We look forward to your enrolment and wish you the best of success! |

DECLARATION

I certify that the above information is true and complete. I understand that any false or incomplete information submitted in support of my application may invalidate my application and result in the withdrawal by Evergreen College of an offered seat at any time during my enrolment.

Applicant’s Name:      

Applicant’s Signature: Date:      

Downtown Toronto Campus

67 Yonge Street, Suite 402, Toronto, Ontario M5E 1J8 Canada

Tel: 416.365.0505 Fax: 416.365.0504

Toronto | Calgary | Montreal

Brampton | Markham | Mississauga |Scarborough

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