VISITING UNDERGRADUATE STUDENT

AUTHORIZATION TO REGISTER
Office of the Registrar 46

A Have you previously applied to/registered at this University?

… No … Yes Concordia I.D. Number

I am applying to register for the following semester: … Summer/1 … Fall/2 … Winter/4 20

I am a visiting student from: University / Institute in:

… Arts … Science … Commerce … Administration … Engineering … Computer Science … Fine Arts … Other

B Please Print Clearly — (NAMES; must reflect the names indicated on your supporting documents.)

Name
Family Name Given Name Family Name at Birth

Date of Birth
Sex … Male … Female
Day/Month/Year

Telephone: Home ( ) Other ( )

Area Code Area Code

E-mail:

Address
Street Number Street Name Apt. Number

City Province/State Country Postal/Zip Code

Language normally used at home at time of application (Please specify if more than one.) First language … English … French

… English … French … Other … Other

Citizenship (please check one and provide documentary proof)

I am a … Canadian Citizen … Member of the First Nations … Permanent Resident
Country of Citizenship

… I am an international student on a From

Authorization Permit Country of Citizenship

All students are required to have a permanent code assigned

C MELS Code Permanent (if available) by the Québec Ministry of Education, of Leisure and Sport.
All candidates should complete this section.
Father’s Name
Family Name Given Name

Mother’s Name
Family Name Given Name

Your Place of Birth

City Country Province (if in Canada)

D Quebec Residency — If you are eligible to establish Quebec Residency status please visit the website QuebecResidency.concordia.ca
for details.

Completed form must include all relevant supporting immigration status documents and letter of permission allowing you to take courses
at Concordia University from your home university.
I hereby acknowledge that, should I receive authorization from Concordia University to register as a Visiting Student, I will be bound by and undertake to observe
the statutes, rules, regulations, and policies in place at Concordia University and at the faculty or faculties in which I am registered, including those policies con-
tained in the University calendars. I agree to provide information for the creation or verification and use of a permanent code assigned by the Québec Ministry of
Education, of Leisure and Sport.
My obligations commence with the signing of this agreement and terminate in accordance with the University's statutes, regulations, and policies. I certify that all
statements on this application are correct and complete. I understand that my authorization to register or registration is subject to cancellation at the sole discretion
of the University.

Student’s Signature Date

UES410 73100 (7/07)