BURSARY APPLICATION FORM (2012)
Fields marked with an asterisk (*) are mandatory.
Applicant Information
* First Name: / * Last Name: / M.I.:* Address:
* Phone: -- / Fax: --
* Email:
Parents information
* Father’s Name: / CPAC Membership# (if applicable):* Mother’s Name: / CPAC Membership # (if applicable):
* Phone: -- / Fax: --
*Family Net Income: $
ACADEMIC Information
* Year in University/College: / * Major:M.I.
* Faculty/Department: / * University/College:
Degree in pursuit of:
* Average mark of last 2 semester, in percentage (eg 95):
sUMMARY
* In 200 words or less, explain why you are the ideal candidate for the CPAC Bursary.Activity information
List of Awards:1)
2)
3)
4)
5)
REFERENCE INFORMATION
(Minimum one academic reference, please no family members)Reference 1: / Reference 2:
Address: / Address:
Phone: -- / Phone: --
Relation to Applicant: / Relation to Applicant:
additional information
If asked, will you be able to provide the following?* Proof of Enrolment (e.g. tuition receipt): Yes No
* Notice of Assessment from most recent year of the whole family: Yes No
* Transcript of the last two semesters: Yes No
DISCLAIMER
* By checking yes, I certify that all of the above information provided is true and complete to the best of my knowledge.Yes
SIGNATURE
Sign below only if you are printing this application to be mailed or faxed.Signature: / Date:
The deadline to apply is October 5, 2012.
Please note that there are two steps to the process. The online form must be completed and submitted prior to completing this form.
This form may be:
1) Completed electronically and emailed to with the subject heading “Attention: CPAC Bursary Application”, OR
2) Completed by hand and faxed to CPAC at (416) 298-0068, OR
3) Completed by hand and mailed to the CPAC office: 4150 Finch Ave E., Toronto, ON M1S 3T9.
Please send your completed application only once.