Bursary Application Form Page 2 of 2

Bursary Application Form Page 2 of 2

CTV BURSARY APPLICATION FORM

(Applications must be completed in full and returned no later than September 30th to the Northern College campus you are applying to)

The information that is gathered in this application is strictly confidential.

Name: ______

Social Insurance Number:______

Complete Mailing Address:______

E-Mail: ______

Age as of September 1 current year :______What is your term average this year ______

Northern College Program you are enrolled in:______Campus: ______

Please check one: Presently in my o1st o2nd o3rd year of my program.

Please remember to attach any other supporting documentation as required for this Bursary.

(a)  A copy of your most recent transcript

(b)  One letter of reference from either an employer, teacher, community leader or business person who is familiar with your achievements

1.  Are you solely responsible for your education costs? o Yes No o

If “no”, who is assisting you and how much are others contributing to your education costs? ______

2.  Number of dependants? ______

3.  Marital Status: o Single o Married/Common Law o Separated

4.  Are you applying for OSAP? o Yes o No

The following information will assist us in determining financial need. You may attach additional pages if necessary.

5.  Additional financial information

(i.e. Are your parents assisting more than one child through postsecondary education?)

o Yes o No If yes, how many? ______

Have you experienced recent personal or parental financial hardships? o Yes o No If yes, please explain

I hereby attest that I am a full-time resident of Ontario and that the information provided is true and accurate to the best of my knowledge.

I understand that I may forfeit my opportunity to receive any bursary from Northern College should this information prove to be deliberately false.

______

Signature

______

Date

Important Notes:

(a)  Bursaries are automatically applied against any balance owing to the College. If no outstanding balance exists, a cheque will be issued to the student for either the full or remaining amount.

(b)  Northern College reserves the right to limit the number of bursaries awarded to students.

(c)  All full-tuition bursaries are paid in two equal installments (Fall and Winter semester)

Please send your completed application form along with supporting documentation by September 30th to the Northern College Campus you are applying to. Incomplete applications or those that are received after the deadline date will not be considered.

Attention: Bursary Selection Committee

Timmins (Porcupine) Kirkland Lake Haileybury Moosonee

P.O. Box 3211 140 Government Rd. E. P.O. Box 2060 P.O. Box 130

Timmins, ON Kirkland Lake, ON ` Haileybury, ON Moosonee, ON

P4N 8R6 P2N 3L8 P0J 1K0 P0L 1Y0

If you have any questions, please do not hesitate to contact the Financial Aid or Student Services office nearest you:

Timmins (Porcupine) Kirkland Lake Haileybury Moosonee

(705) 235-3211 (705) 567-9291 (705) 672-3376 (705) 336-2913