First Name: Last Name:
Street Address: Apt./Unit#:
City/Town: Province: Postal Code:
Email:
Home Phone Cell Phone
Gender: Female Male Other Gender Date of Birth (mm/dd/yyyy)
Student ID
Listed below are entry requirements to process this application. PROOF of attained credits must be attached.
Faculty of Continuing Education
06-28-19
Medical Device Reprocessing Program Admission Request Form
Signed: Date:
FREEDOM OF INFORMATION AND PROTECTION
OF PRIVACY ACT
Personal information on this form is collected in accordance with
sections 21, 39 and 49 of the Freedom of Information and Protection
of Privacy Act and under the legal authority of the Ministry of Training,
Colleges and Universities Act, R.S.O. 1990, and the Ontario Colleges
of Applied Arts and Technology Act, 2002, Regulation 34/03, and may
be used and/or disclosed for administrative, statistical and/or research
purposes of the College and/or the ministries or agencies of the
Government of Ontario and the Government of Canada. If you
have any questions concerning the collection and use of personal
information, please contact the Privacy Oce at (416) 491-5050
extension 77846 or email privacyoce@senecacollege.ca.
Faculty of Continuing Education OFFICE USE ONLY:
Date stamp and forward to:
Attention: Part-time Medical Device Reprocessing – Admissions
mm/dd/yy
Requirement Name of attached supporting document or transcript
English: Grade 12 (C) or ENG4 or College English
