Centre for Integrated Studies

PBDLD Supplemental Program Application

Program applicants MUST complete Parts A, B, and C of this questionnaire. Part D is optional however we request this information to assist us with student retention and recruitment. Failure to complete sections A, B, and C will result in a delay in the processing of your program application. Please submit all completed documentation at once.

Part A: Personal Information

Name (Last, First): / Address:
City: / Province/State:
Country: / Postal Code:
Phone (Residence): / Phone (Business):
Fax: / E-mail:
Gender: Male  Female
 No response / Dater of Birth (YYYYMMDD):
  1. As a student, do you have special needs related to a physical, medical, psychological, learning disability or other limitation? If you answer “yes” or “unsure” your application will be forwarded to AthabascaUniversity’s Access to Students with Disabilities department for further assistance.

No ____ I do not wish to respond ____ Uncertain _____ Yes ____

2. Do you have regular access to a computer? Yes ___ No ___

3. Do you currently have an Internet service provider? Yes ___ No ___

  1. It is the responsibility of each student to have access to a computer system equivalent to that noted online: (

Does your computer system currently meet these requirements?

Yes ___ No ___

Part B: Academic Background

1. Have you ever taken a course at AthabascaUniversity? Yes ____ No ____

If “Yes”, please provide your AU student ID number:

2. Are you currently enrolled in another university program? Yes ____ No _____

If “Yes”, please specify:

3. List in order, beginning with the latest, all post secondary work. You are required to request that transcripts be sent directly from each institution listed below to AthabascaUniversity. Applications will not be processed until the official transcript(s) listed below have been received directly from the granting institution.

Degree:

Dates Attended:

College or University: /

Area of Specialization:

Date Convocated:
Location:
(Prov./State & Country)
Degree:

Dates Attended:

College or University /

Area of Specialization:

Date Convocated:
Location:
(Prov./State & Country)
Degree:

Dates Attended:

College or University /

Area of Specialization:

Date Convocated:
Location:
(Prov./State & Country)
Degree:

Dates Attended:

College or University /

Area of Specialization:

Date Convocated:
Location:
(Prov./State & Country)
Degree:

Dates Attended:

College or University /

Area of Specialization:

Date Convocated:
Location:
(Prov./State & Country)

4. Are you an international student? Yes ____ No ____

International Students Only: Applications will not be processed until an IQAS evaluation has been completed and official confirmation of ESL assessment score is received.

Have you requested an IQAS evaluation of your international transcripts? Yes___ No __

Date of request:IQAS file number:

Have you submitted your ESL assessment to CIS? Yes____ No____Score: ______

I agree to abide by the rules and regulations for the Centre for Integrated Studies and the specific program in which I am applying. I certify that the information provided on this form is true and complete in all respects and that no relevant information has been withheld. I agree that AthabascaUniversity retains the right to nullify my application if the information provided is false or incomplete. I certify that I am not under suspension or dismissal from another institution for reasons of academic misconduct. I understand that all documents received in support of this application become the property of AthabascaUniversity.

SIGNATURE:Date:

Part C: Intellectual Biography & CV

Please attach with this application a brief statement of your interests, and how you see yourself working and studying in the CIS program of your choice. Additionally, please include an updated CV with this application. You may include your biography and CV here under section C or send them in the same e-mail in a separate document.

Your Intellectual Biography should be no more than 500 words in essay format and include:

  1. your primary reasons for applying to this type of integrated program of study
  2. your particular intellectual areas of interest in the arts, humanities and social sciences
  3. an outline of what you want to achieve through the program
  4. the particular skills, resources, and experience you have that will facilitate your completion of this degree
  5. additional comments that you would like to make.

Your CV (resume) should include:

  1. your formal education achievements (most recent listed first), including any awards, credentials (certificates, diplomas, degrees, etc.) received
  2. other training/educational experiences that relate to your career and educational goals (e.g., courses, workshops attended)
  3. informal/non-formal activities or life experiences that relate to your career and graduate education goals
  4. relevant work experiences (most recent listed first). These should include enough detail to adequately describe the experiences and your level of responsibility
  5. articles/papers and talks that you have published/presented
  6. your memberships in professional organizations
  7. grants and scholarships received
  8. volunteer, important hobby and community activities in which you have been involved.

Part D: Optional Information (To assist with Recruitment & Planning)

  1. How did you find out about the CIS Program? Please check all applicable items:

AU Calendar ___Internet___Friend ___ Co-worker ___ Employer ___

Relative ___ AU Student ___AU Employee ___

Advertisement in print publication (please specify source):

Other (please specify):

2. Please check all the applicable factors that affected your decision to apply to a CIS Program:

___ Cost ___ Ability to study & continue to work ___ Build own study plan

___ Web component ___ No on-site requirements ___ Reputation of AU

___ Flexible study schedule ___ Student recommendation ___ Distance delivery

___ Integrated curriculum ____ Other (please specify)

  1. What is your current occupation? (Please include job title and industry)
  1. What is your main source of media?

___ TV ___ Radio ___ Internet___ Newspapers ___ Magazines

Other (please specify)

  1. Would you like to see more Paced or more Individualized study course offerings?

Paced courses are those beginning in September, January and May, in which students proceed through a course with a cohort and participate in on-line asynchronous learning activities. Individualized study courses are those which begin on the first day of every month and are primarily self-directed studies, which may include an on-line discussion component.

Please briefly explain your answer:

The personal information collected on this form and any other personal information collected and maintained as part of a student's record will be used for the purpose of admission, registration, issuing income tax receipts, scholarships and awards, convocating, for sending educational material and information, and for university research and planning. Certain personal information will also be disclosed to Statistics Canada, as required by the Statistics Act (Canada), and Alberta Learning to meet reporting requirements. This information is collected under the authority of the Alberta Universities Act that mandates the programs and services offered by AthabascaUniversity and section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. It will be protected by the Alberta Freedom of Information and Protection of Privacy Act. If you have any questions about the collection and use of this information, contact the Centre for Integrated Studies, AthabascaUniversity, 1 University Drive, Athabasca, ABCanadaT9S 3A3, Telephone: (780) 675-6792