Please check one:

Office use only
Application for Exchange Student Admission
ENROLMENT SERVICES/ADMISSIONS • 424 University Centre • Winnipeg, Manitoba • Canada R3T 2N2 • Telephone: (204) 474-8808 • FAX (204) 474-7554
Please check one:
Undergraduate Courses (1000 to 5000 level)
If you are applying to the Asper
school of Business, return
completed application to:
If you are applying to any other
faculty, return completed
applications to:
Student Exchange Coordinator
Student Exchange Coordinator
Asper School of Business
International Centre for Students
268 Drake Centre
The University of Manitoba
Winnipeg, Manitoba R3T 2N2
Canada
541 University Centre
The University of Manitoba
Winnipeg, Manitoba R3T 2N2
Canada
Graduate Courses (6000 level & higher)
Application deadlines:
April
1
for September start date
September 1
for January start date
January 1
for May/June or July start date
Fax: 1-204-474-7562
Fax: 1-204-474-7529
1 Previous application
4 Primary language
Please print
Have you ever applied for admission to the University of Manitoba?
Yes
No If 'yes', Faculty and year of application:
English
French
Other (specify): ______________________
If English was not your first language, indicate the number of years of
English instruction you have received: _________________
Faculty: ________________________ Year : | __ | __ | __ | __ |
If 'yes' did you register and attend classes?
Yes; year last registered: | __ | __ | __ | __ |
(primary language refers to the mother tongue)
No
If you have written any of the following: T.O.E.F.L., CanTEST, M.E.L.A.B.,
I.E.L.T.S., enter the name and date of last writing or date it is to be written.
U of M student number (if known) : | ___ | ___ | ___ | ___ | ___ | ___ | ___|
Test: __________________ Date written: __________________________
2 Date and duration of program
5 Mailing addresses
Indicate your preferred start session:
Current Mailing address
Regular Session: September to December 20___
valid until ________________________
Post office box or number and street
Regular Session: January to April 20___
City or town and province
Intersession: May and June 20___
Summer Session: July and August 20___
Country
Anticipated end date of program:
Month ________
Home telephone
(
)
3 Personal information
Facsimile
(
)
E-mail:
Family name
Permanent home address
First name and middle name(s). Use full legal names (no initials).
(if different from above)
Post office box or number and street
Previous or other names
Date of birth (year/month/day)
Place of birth (province or country)
Country of permanent residence
Title (Mr., Miss, Ms, Mrs., Dr.,
Rev.)
Gender:
Male ___ Female ___
Postal code
Year _________
Citizenship
Citiz
enship and immig
tus
Citizenship
immigrration sta
status
You must check one box.
Canadian Citizen Date of entry if not born in Canada: | __ | __ | __ | __|
Year
Permanent Resident
City or town and province
Country
Postal code
Home telephone
(
)
Facsimile
(
)
Emergency Contact Person
Name
Month
Date of entry: | __ | __ | __ | __ |
Year
Month
International student on Student Authorization (Student Visa)
Relati onshi p
Date of actual or proposed entry into Canada: | __ | __ | __ | __ |
Year
Month
Passport Number: _________________________________________
Emai l Address
Home telephone
(
)
6. Academic History
Please provide a complete listing of all post-secondary institutions you have attended or are attending. Please attach additional sheet if required.
University or college:
From
To
Yr. /
Mo.
Yr. /
Mo.
C urrent:
/
/
Previous:
/
/
/
/
N ame of
Institution
Location
Program in w hich
you w ere
enrolled (e.g.
B .A., B . Sc., etc.)
7. Home Institution Exchange Approval
D egree C onferred
Major Subject
Yes / D ate
N o / highest level
completed
Name of home institution: _________________
Choose one:
Bilateral Exchange
Consortium Exchange
This student has been selected according to the terms of the
Student Agreement between the University listed above and the
University of Manitoba and is nominated for exchange student
admission under the terms of this agreement
This student is applying to the UofM through its participation in this
exchange consortium.
Check one:
CONAHEC
North2North
RAMP
IBSEN
Mobility project though faculty of:__________________
Other:______________________________________
Exchange Coordinator's name (please print):
Exchange Coordinator's signature:
Exchange Coordinator's email:
Date:
8. Study plan
List the courses you plan to take while at the University of Manitoba. Please ensure that you have the prerequisites for the courses you select
and that they are offered in the correct semester for the time you will be here. List courses in preferred order (3 to 5 courses per semester).
Course information can be found in the University of Manitoba Calendar on the internet at http://webapps.cc.umanitoba.ca/calendar The Registration
Guide is also on the internet. (If you are applying before the next session's Calendar and Registration Guide are on the website, please use the
previous year's as a guideline.) Please attached a seperate sheet if more space is required.
U of M Course Code
Course Title/Description
Course Dates
9. Home Institution Faculty Approval
(To be completed by the Dean of your Faculty, Registrar or Equivalent officer):
I confirm that the above applicant is currently a student in good standing at this institution and has been permitted to take the courses listed
above
at the University
of Manitoba
as part of their
degree program.
9.
Home
Institution
Faculty
Approval
9. Home Institution Faculty Approval
(To
be completed
by the
Dean of your Faculty, Registrar
or Equivalent
officer):
Name
(please print):
_____________________
Position:
____________________
Faculty: __________________ Date: ____________
be completed
by the applicant
Dean of your
Faculty,aRegistrar
or good
Equivalent
officer):
I(To
confirm
that the above
is currently
student in
standing
at this institution and has been permitted to take the courses listed
I confirm
thatUniversity
the above applicant
is as
currently
student
in good
standing at this institution and has been permitted to take the courses listed
above
at the
Manitoba
of atheir
degree
program.
This student
is currentlyofenrolled
in thepart
following
degree
program
at their home insitution: _____________________________________
above at the University of Manitoba as part of their degree program.
Name
(please
print): _____________________ Position: ____________________ Faculty: __________________ Date: ____________
Signature:
_______________________________
Name (please print): _____________________ Position: ____________________ Faculty: __________________ Date: ____________
This student is currently enrolled in the following degree program at their home insitution: _____________________________________
This student is currently enrolled in the following degree program at their home insitution: _____________________________________
10. Declaration
Signature:
_______________________________
Notice Regarding Disclosure of Personal Information to Statistics Canada
Signature:
_______________________________
Please
read all
application materials carefully. Failure to disclose relevant
facts (including ALL previous attendance at post-secondary institutions) and/
or submission of false information or documentation may result in acceptance and registration being withdrawn. If this information is discovered in a
subsequent
it may result
in dismissal
the University.
Please
readsession
all application
materials
carefully.from
Failure
to discloseRegistration
relevant
at
a
post-secondary
institution
subsequent
to
the
submission
of thisrelevant
applicafacts
(including
previousmaterials
attendance
at post-secondary
institutions)
and/
Please
read all ALL
application
carefully.
Failure to disclose
tion
must
be declared
in
writing.
or
submission
ofALL
false
information
or documentation
may result
in acceptfacts
(including
previous
attendance
at post-secondary
institutions)
and/
10. Declaration
10. Declaration
ance
and of
registration
If of
this
information
discovered
in a
or submission
of falsebeing
information
or documentation
may is
result
in acceptFreedom
Information
andwithdrawn.
Protection
Privacy
Act
subsequent
session
it being
may isresult
dismissal
from
the
Registration
ance
and registration
withdrawn.
If thisunder
information
is discovered
T
his personal
information
beingin collected
the University.
authority
of
The in a
at
a post-secondary
subsequent
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this
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itinstitution
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in
from
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University
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Manitoba
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It will
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used for
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tion
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be
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student.
may
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institutions,
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Freedom
Information
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departments,
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for
those students
Freedom
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University
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University
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degrees,
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and
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University’s
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Information
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Students’
Union.
Upon graduation,
the student’s
and address,
together
are members
of UMSU,
it will be disclosed
to thename
University
of Manitoba
of
Privacy
provisions
ofgraduation,
The Freedom
Information
Protection
of
with
information
on
degrees,
diplomas,
and
certificates
earned
will be
given
Students’
Union.
Upon
the of
student’s
nameand
and
address,
together
Privacy
Act. If you
have
questions
the collection
of to
personal
to
and
maintained
theany
alumni
recordsabout
department
in order
assist
with
information
onby
degrees,
diplomas,
and
certificates
earned
will
be the
given
information,
contact
the
FIPPA/PHIA
Coordinator’s
Office
(tel.
204-474University’s
advancement
and development
efforts. Information
to and maintained
by the alumni
records department
in order to regarding
assist the
8339),
University
of Manitoba
& Special
Collections,
Elizabeth
graduation
and
awards
may
beArchives
made public.
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by 331
the
Protection
University’s
advancement
and
development
efforts.
Information
regarding
Dafoe
Library,
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If
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information
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Privacy
Act.provisions
you have
any Freedom
questions
about
the collection
of personal
of you
Privacy
of another
The
Protection
behalf,
please
complete
the
FIPPA
release
form
available
from
our
office
information,
the FIPPA/PHIA
Coordinator’s
Office (tel.
204-474- or
Privacy Act. contact
If you have
any questions
about the collection
of personal
on
our
website.
8339),
University
of the
Manitoba
Archives
& Special Collections,
331 Elizabeth
information,
contact
FIPPA/PHIA
Coordinator’s
Office (tel. 204-474Dafoe
Winnipeg,
Manitoba,
Canada,
R3T Collections,
2N2.
8339), Library,
University
of Manitoba
Archives
& Special
331 Elizabeth
If
you wish
to authorize
person
to access
Dafoe
Library,
Winnipeg,another
Manitoba,
Canada,
R3Tyour
2N2.information on your
Date:
________________________
behalf,
please
complete another
the FIPPA
release
form available
from ouronoffice
If you wish
to authorize
person
to access
your information
your or
on
our website.
behalf,
please complete the FIPPA release form available from our office or
on our website.
11. Required Documentation
Date: ________________________
Date: ________________________
The Federal Statistics Act provides the legal authority for Statistics Canada to
obtain access to personal information held by educational institutions. The
information may be used only for statistical purposes, and the confidentiality
provisions
of the Statistics
Act of
prevent
the Information
information from
being released
Notice
Regarding
Disclosure
Personal
to Statistics
Canadain
any
way
that Statistics
wouldDisclosure
identify
a student.
The
Federal
Act provides
the legal
authority for
Notice
Regarding
of Personal
Information
to Statistics
StatisticsCanada
Canadato
At
time, students
who
not wish
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ask
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Canada
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Further
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by writing
to the Post-Secondary
At
who doa not
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Section,
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R.H.
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At any
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Further
details on the use of this information can be obtained from Statistics
Transcript
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Canada's
web
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or bycan
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Further details
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I hereby
authorize
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ofR.H.
Manitoba
transcript
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Tunney's
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be sentPasture,
directly Ottawa,
to my home
institution.
Transcript Release
Transcript
•Declaration
I hereby Release
authorize the release of my University of Manitoba transcript to the
of Manitoba
Student
Coordinator,
in order
that
may
authorize
release
my understood
University
ofthe
Manitoba
transcript
to
the
• University
I hereby certify
thatthe
I have
readofExchange
and
instructions
and itinformabe
sent
directly
to my home
University
ofapplication
Manitoba
Student
Exchange
Coordinator,
in order
tion
on this
form institution.
and
on the Application
Guide
and that
that itallmay
be sent directly
home institution.
statements
madetoinmy
connection
with this application are true and complete.
Declaration
• I authorize the University to verify any information, transcripts, or reference
provided
as part
of this
•Declaration
Iletters
hereby
certify that
I have
readapplication.
and understood the instructions and informaon this
application
formread
andfalsified
on understood
the documents
Application
Guide
that
all the
hereby
certify
I have
and
the may
instructions
andwith
informa• tion
I accept
that
anythat
information
on
be and
shared
statements
in connection
with
application
are true
and
complete.
tion
on this made
application
form
andUniversities
on this
the Application
Guide
that
all
Association
of
Registrars
of the
and Colleges
of and
Canada.
made
in connection
with
application
are true and
complete.
• Istatements
authorize the
University
to verify
anythis
information,
transcripts,
or reference
provided
as part________________________________________
oftothis
application.
• letters
I Student's
authorize
the
University
verify
any information, transcripts, or reference
signature
part of this
• Iletters
acceptprovided
that anyasinformation
onapplication.
falsified documents may be shared with the
Registrars
of the
and Colleges
of shared
Canada.with the
• Association
I accept thatofany
information
on Universities
falsified documents
may be
Association of Registrars of the Universities and Colleges of Canada.
Student's signature ________________________________________
Student's signature ________________________________________
• Official transcripts. You must arrange to have official transcripts forwarded
11.
Required Documentation
along with the application form to the International Centre for Students
11.
Documentation
Office.Required
Student copies or photocopies
are not acceptable. Transcripts become the
••
•
•
•
•
•
•
property of U of M and will not be returned.
Name change
documentation.
your name
has changed
as a result forwarded
of marriage,
Official
transcripts
. You must If
arrange
to have
official transcripts
divorce
or
other
appropriate
must be
supplied.
along
the reason,
application
form
todocumentation
the to
International
Centre
for Students
Officialwith
transcripts
. You
must
arrange
have official
transcripts
forwarded
English
language
proficiency.
If your
primary
languageCentre
is
otherfor
than
English,
Office.
Student
or photocopies
are
not
acceptable.
Transcripts
become
theyou
along with
the copies
application
form
to the
International
Students
must
demonstrate
that will
you
arebe
proficient
theacceptable.
use of the English
language.
This
property
of U of M
and
not
returned.
Office.
Student
copies
or photocopies
areinnot
Transcripts
become
the
includes
Canadian
Citizens
& Permanent
Residents and applicants on Student Auproperty
of
U ofdocumentation.
M and
will not
beIfreturned.
Name
change
your name has changed as a result of marriage,
thorization (Visa). A brochure with detailed information on English language profidivorce
or otherdocumentation.
reason, appropriate
documentation
must be as
supplied.
Name change
If your
name has changed
a result of marriage,
ciency may be obtained from our office.
divorce orlanguage
other reason,
appropriate
documentation
must be
English
proficiency.
If your
primary language
is supplied.
other than English, you
must
demonstrate
you are proficient
in the use
of the English
Thisyou
English
languagethat
proficiency.
If your primary
language
is other language.
than English,
includes
Canadian that
Citizens
Permanent
applicants
on StudentThis
Aumust demonstrate
you &
are
proficient Residents
in the use and
of the
English language.
thorization
(Visa). ACitizens
brochure
detailedResidents
information
onapplicants
English language
profiincludes Canadian
& with
Permanent
and
on Student
Auciency
may(Visa).
be obtained
fromwith
our detailed
office. information on English language profithorization
A brochure
ciency may be obtained from our office.
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
University of Manitoba Faculty/Department approval:
University of Manitoba Faculty/Department approval:
This student has been approved to study in the Faculty
USE
This student has FOR
beenOFFICE
approved
to ONLY
study in the Faculty
University of Manitoba Faculty/Department approval:
Approval
granted
by (please print)
of __________________________
as an exchange
student.
University
of Manitoba
Faculty/Department
approval:
of __________________________
an exchange
FOR OFFICEasUSE
ONLY student.
Name:
______________________________________________
Approval granted by (please print)
This student
has been approved to study in the Faculty
Title:
_______________________________________________
This student has been approved to study in the Faculty
Name: ______________________________________________
Signature:
___________________________________________
of __________________________
as an exchange student.
of __________________________
as an exchange student.
Date:
_______________________________________________
Title: _______________________________________________
Approval granted by (please print)
Approval granted by (please print)
Signature: ___________________________________________
Name:
______________________________________________
For
Graduate
Student Applicants:
Name: ______________________________________________
Date:
_______________________________________________
This
has been approved to study in the Department
Title:student
_______________________________________________
Title:
_______________________________________________
of
__________________________
as an exchange student.
Signature: ___________________________________________
Approval
granted
by (please print)
Signature:
___________________________________________
Date: _______________________________________________
Name:
______________________________________________
Date: _______________________________________________
Title:
Signature:
Date:
_______________________________________________
___________________________________________
_______________________________________________