Application Form - English as a Second Language

Continuing Education - English as a Second Language

1. Course information

Please Specify Your Course Selection:*

Indicate the semester for which you are applying:*

Indicate the year for which you are applying:*

I would be interested in taking this course online, if available.

Yes

No

2. Documents required: (In order for your application to be processed, all required documents must be submitted)

Valid Government Identification (Required for non-credit courses). Can be one of:
a. Passport
b. Drivers License
c. Health Card
Please include a photo/scan of both the front and back of your proof of identification

Proof of Identification Front:*

Proof of Identification Back:*

3. Personal Information

Family Name:*

First Name:*

Date of Birth:*

Gender:*

Male

Female

4. Permanent Address (PLEASE NOTE: It is YOUR responsibility to notify us of any changes)

Number:*

Street/Rural Route/P.O. Box:*

Apartment:

City/town:*

Province:*

Country:*

Postal Code (important):*

Telephone:*

Secondary Telephone:

Email:*

5. Québec residents may be eligible for a subsidy for part-time training offered by Services Quebec.

The subsidy is applicable to select beginner and intermediate level English Second Language, courses only.
If, after review, you are eligible, your cost for the course will be reduced to $200, plus cost of course book.
IMPORTANT: Full-time students and workers in government departments and agencies financed by public funds are excluded.
To apply for the subsidy, please complete sections 5.1, 5.2 & 5.3

5.1 Course information

Course title

Start date:

How can this training improve your employment situation?

5.2 Education Information

Level of studies:

Field of studies:

Degree obtained:

Yes

No

5.3 Situation facing the labor market

Situation in the labor market

Number of hours worked / week:

Job title or job sought:

If employed - Company name:

Company address:

Sector:

7. Certificate and Signature

I certify that the information provided is correct.
If I am a Québec resident I also authorize Emploi-Québec and the training establishment offering the above measure to exchange the personal information necessary for the realization and the follow-up of my participation for the subsidy.

Signature:

Date:

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Application Form - English as a Second Language

Continuing Education - English as a Second Language

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Pontiac Campus

Continuing Education - English as a Second Language

Student Services

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