International Student Services Emergency Loan & Bursary Fund Application

Transcription

1 Office Use Only Advisor Name International Student Services Emergency Loan & Bursary Fund Application Please submit the following documents together with the application form: Copy of your Study Permit Copy of your proof of funds used for your most recent Temporary Resident Visa & Study Permit application Copy of your most recent monthly bank statement for all of your accounts, including those of your spouse/partner Copy of your residence contract/lease agreement and recent proof of housing payments Any receipts for costs incurred with extenuating expenses General Information First Name: Address: Province: Home Phone: UAlberta Faculty: Last Name: City: Postal Code: Cell Phone: Student ID Number: Department: Undergraduate Graduate Exchange/Visiting/Sponsored Home Country: Expected Graduation Date: Date Arrived in Canada: Study Permit Expires: Financial Information Cash resources available on hand: Monthly Income: On-campus Monthly Income: Off-Campus Number of dependents living with you: Available funds in the Bank: Income from other sources: List other sources: Spouse s Monthly Income (if applicable): What is your income after tuition deduction? $

2 Have you received any previous assistance from the International Student Services? Yes No If yes, please indicate if it was a loan or bursary, the amount and date approved: Have you received any other bursaries, scholarships or awards while at the University of Alberta? Yes No If yes, please state the bursary, scholarship and/or award. Specify the grounds on which you were approved and the date you received it. Please enter your information as follows: Title - Amount - Date - Reason: List any present debts, who you owe and what is the repayment plan?

3 Why do you need this bursary/loan? Please explain how your need was unforeseen, and could not be pre-planned and budgeted for: Monthly Living Expenses Accommodation $ Dental/Pharmacy $ Utilities (if not $ Food $ included in rent) Non-University $ Clothing $ health insurance paid out of pocket Health Care costs $ Telephone/Cell $ paid out of pocket Transportation (not $ Other $ including U-Pass) Total $

4 Annual Academic Costs Tuition and Fees $ Books, Computer Software, Supplies $ Thesis Costs (if applicable) $ Total $ Requested amount of funds: $ Date: Do you expect this to be a recurring issue? Yes No If yes please explain: If refused, how do you plan to resolve your financial need?

5 DECLARATION (please read before signing - unsigned applications will not be considered for funding) I declare that the information provided on this application and all attachments are true. I understand that all the information provided is subjected to verification. I agree to notify the International Student Services (ISS) in writing if I change my address, financial or academic status, or study period, or if my guarantor s address changes. I understand that I may be denied financial assistance if: I am not currently a University of Alberta student I make a false or misleading statement in this application I do not comply with a request from (ISS) to provide information or documents to verify information in this application I have already been awarded a previous UAlberta Bursary in the current year I have read, understood and agree to the following: This personal information is being collected under the authority of Section 33(c) of the Freedom of Information and Protection Privacy (FOIPP) Act. The personal information will be used for loans and bursary eligibility assessment purposes and the aggregate data will be used for evaluation and statistical summaries. The University of Alberta may directly contact Revenue Canada, other federal departments, provincial or municipal departments, employers, financial and educational institutions without your further consent, when necessary, to determine and verify your eligibility for the ISS emergency loan or bursary. All information collected by the International Student Services at the University of Alberta is protected by provisions of the FOIPP Act. If you have any questions about the collection, use, or disclosure of your personal information, contact International Student Services, Associate Director at I consent to the review of my student record and discussion with other University departments for the purpose of determining my eligibility for a bursary and/or loan. Name: Date: Signature: Date: (Signed at end of interview) (Date of interview) For administrative use only: Emergency Loan Emergency Bursary Approved amount: $ ISS staff: Date approved: