Personal Information

English Language Proficiency

Is English your first language?
Yes
No, my first language is:

(If no, proof of English language proficiency is required.)

Citizenship Status

Canadian Citizen
Permanent Resident
Refugee with protected person status
Other (Please specify below)

Country of Citizenship (if not Canadian)

Program Choices

Preferred program choice Location

Second program choice Location

Application Fee

Visa Mastercard Discover American Express Cheque/Money

Credit card number

Exp. Date (mm/yy)   Name of Cardholder   Cardholder’s signature

Educational History

High school or GED:

Name of school Grade completed Date

Previous community college, university and/or other education:

Name of Institution Degree/Diploma Year completed

Name of Institution Degree/Diploma Year completed

Health Human Services Applicants

Have you been convicted of a criminal offence for which you have not received a pardon?

Yes No

Have you been convicted of an offence or investigated for an activity resulting in your name being placed on the Child Abuse Registry?

Yes No

Have you ever received any disciplinary actions (including any revocation of your licence to practise) as a member of another health and human service organization?

Yes No

Self-identification Questionnaire

Do you self-identify as an Aborginal person?

Yes No

Do you self-identify as a member of the African Canadian community?

Yes No

Do you self-identify as a person with a disability?

Yes No

If you require accommodation, please provide documentation of disability:

Enclosed I will forward it On file with NSCC Admissions

Additional Information

Certification

I understand that it is my responsibility to arrange for the submission of the transcripts and that the application without complete documentation cannot be considered regardless of submission date. I certify that the foregoing information is accurate and correct to the best of my knowledge. I understand that the College will collect, use, and disclose my personal information in a confidential manner that is consistent with the operation of a post-secondary institution. My consent is conditional upon Nova Scotia Community College complying with their legal duties and obligations to manage the collection, use, and disclosure of personal information.

Applicant Signature Date (mm/dd/yyyy)

Permission to Release Personal Information

I hereby give consent to the release of the information concerning my application for admission during the evaluation period to:

Name

Relationship (e.g. Parent, guardian, guidance counsellor, spouse)