STUDENT RECORDS:

Have you ever previously registered for the C.Log. program, or applied for a

program at the University of Manitoba? ____ Yes ____No

If YES UofM Student Number (if known) ______

Program/Faculty you applied to: ______Year of application ______

Last Year registered at UofM ______

STUDENT INFORMATION:

*LAST NAME:______*FIRST NAME:______

*DATE OF BIRTH (YY/MM/DD) ______

HOME ADDRESS:______CITY/TOWN______

PROVINCE:______POSTALCODE______

DAY PHONE: ______EVENING PHONE ______

*EMAIL______*CITIZENSHIP______

*INDICATES REQUIRED INFORMATION

OCCUPATIONAL HISTORY (please complete in full)

Job Title______Employer______

Employer Address______City/Town______

Province______Postal Code______

Business Phone______Business Fax______

Preferred Mailing Address _____Home _____Business

Job Responsibilities______

______

______

EDUCATIONAL HISTORY (please complete in full)

Highest level of formal education achieved______Name of educational institution______

Location of educational institution______Date______

Additional training/courses completed or professional standing achieved:

______Date______

______Date______

Where did you first hear about this program?______

APPLICATION FEE

Certificate in Logistics – Application to the Program Fee (a one time admission fee) _____ $100

SIGNATURE

___ I have read the prerequisite(s) for the course(s) I am applying for and meet the requirements (requested

documents are enclosed.)

Student number:______Signature:______Date:______

Notice Regarding Collection, Use and Disclosure of Personal Information by the University

Your personal information is being collected under the authority of the University of Manitoba Act. The information you provide will be used by the University of Manitoba for the purposes of communication, and to process payment. Your personal information may be disclosed to other educational institutions, government departments and co-sponsoring organizations, and, for those students who are members of UMSU, it will be disclosed to the University of Manitoba Students’ Union. Your personal information will not be used or disclosed for other purposes, unless permitted by the Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information, contact the Access & Privacy Office (204.474.9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB R3T 2N2.

METHOD OF PAYMENT: (All applicable fees must accompany program application form)

___Cash (in person only) ___Cheque/money order – Payable to the University of Manitoba (No postdated cheques)

___Invoice Employer – A request to invoice must be on letterhead and authorized by an official of the employer or sponsoring agency.

___Payment by Credit Card – Complete the following section.

____ VISA _____ MasterCard

Cardholder’s Name (as it appears on the card)______

Amount $______Authorizing Signature______

Card #______Exp. Date______

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