INTERNATIONAL
Within Reach. Beyond Imagination. 1 888 953 1133 selkirk.ca
EDUCATION ABROAD
APPLICATION FORM
Please ll in all sections. Please notify Selkirk International of any changes to your contact information.
Last Name: First Name:
Country of rst choice: Country of second choice:
Length of trip - Semester 1: Length of trip - Other:
Start Date: End Date:
Last Name: First Name: Phone:
Middle Name: Previous Last Name:
Program:
Credit hours completed (incl. current term):
Languages spoken and/or studied other than English:
Why are you interested in studying abroad?
Date of Birth (yy/mm/dd): Email:
Address: City Postal Code:
Area Code: ( ) Phone Number: Can we leave a message at this number? Yes No
NEXT OF KIN – EMERGENCY CONTACT
EDUCATION ABROAD OPPORTUNITY
CURRENT ACADEMIC INFORMATION
PERSONAL INFORMATION
Citizenship: Canadian Permanent Resident Other Student ID Number:
Approximate Application submission dates to Selkirk International on or before:
November 15 for Winter departures – February 15 for Spring departures – April 15 for Fall departures
Contact Cari-Ann Roberts Gotta (A11)
cgotta@selkirk.ca for more information.
