Form (2016) – Page 1 of 2 The information collected on this form will be stored in the Personal Information Bank for the appropriate program. PROTECTED B WHEN COMPLETED Version française disponible Application Form Family name of applicant Given name Initial(s) of all given names Current mailing address Telephone number Email address CITIZENSHIP Canadian Citizen Permanent resident of Canada Date of landing ______________ as stated on official immigration document AGE (mandatory) Are you between the age of 16 and 18 at the deadline date? Yes No GENDER (optional) Male Female Not identified DESIGNATED GROUPS (optional) Indigenous Person with disabilities Visible minority LANGUAGE OF CORRESPONDENCE English French SIGNATURES Signature of Applicant Date _____________ Name of Parent/Guardian (if applicable) Date _____________ Signature of Parent/Guardian (if applicable) Date ___________ _

Application Form€¦ · Form (2016) – Page 1 of 2 The information collected on this form will be stored in the Personal Information Bank for the appropriate program

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Form (2016) – Page 1 of 2 The information collected on this form will be stored

in the Personal Information Bank for the appropriate program. PROTECTED B WHEN COMPLETED

Version française disponible

Application Form Family name of applicant Given name Initial(s) of all given names

Current mailing address

Telephone number Email address

CITIZENSHIP

Canadian Citizen

Permanent resident of Canada

Date of landing ______________ as stated on official immigration document

AGE (mandatory)

Are you between the age of 16 and 18 at the deadline date?

Yes No

GENDER (optional)

Male Female Not identified

DESIGNATED GROUPS (optional)

Indigenous Person with disabilities Visible minority

LANGUAGE OF CORRESPONDENCE

English French

SIGNATURES

Signature of Applicant Date _____________

Name of Parent/Guardian (if applicable) Date _____________

Signature of Parent/Guardian (if applicable) Date ___________ _
Form (2016) – Page 2 of 2 The information collected on this form will be stored

in the Personal Information Bank for the appropriate program. PROTECTED B WHEN COMPLETED

Version française disponible

Application Form

Family name of applicant Given name

ACADEMIC BACKGROUND (Current institution)

Institution __________________________Start date ____________ End date _____________

PROPOSED LOCATION

Institution ___________________________ Department ___________________________

Program of study______________________

ACHIEVEMENT(S) - Describe the achievement(s) for which you were recognized.

AMBASSADOR POTENTIAL - Describe how you will become an ambassador for STEAM fields for younger generations.

INNOVATION/PROBLEM SOLVING - Describe your innovative idea, or plan to solve a real-world problem.

Given name: Initials of all given names: Telephone number: Email address: Family name of applicant_2: Given name_2: Institution: Institution_2: Department: Program of study: ACHIEVEMENTS Describe the achievements for which you were recognizedRow1: AMBASSADOR POTENTIAL Describe how you will become an ambassador for STEAM fields for younger generationsRow1: INNOVATIONPROBLEM SOLVING Describe your innovative idea or plan to solve a realworld problemRow1: Citizenship: OffAge: OffGender: OffDesignated Groups: OffLanguage: OffCurrent mailing address: Family name of applicant: Start Date1: [ ]End Date1: [ ]LandingDate1: [ ]LandingDate3: [ ]LandingDate2: [ ]End Date2: [ ]Sart Date2: [ ]