UNIVERSITY APPLICATION PERSONAL INFORMATION Family Name First Name(s) Date of Birth (year/month/day) Gender Citizenship First Language

_____________________ ___________________________________ _____________________________ __ Male __ Female ________________Japan_____________________ ________________________________

Student Address*for Visa/Study Permit and Acceptance Letter purposes* Street: ______________________________ City/Town and Province: _________________________ Country: ____________________________________ Postal/Zip Code: __________________________________ Phone: _____________________________ Email: __________________ Emergency Contact Name: Phone: Status in Canada: __________________________________ _______________________________ ___ Canadian Citizen/Permanent Resident __ Student Authorization (Study Permit) ___ Visitor ___ Other _________________________________________ _____________________________________ _____ _ __

Agent (if applicable) Name: Address Phone: Email: PROGRAM INFORMATION Requested Start Date __ April 13, 2012 __ August 31, 2012 __ January 4, 2013 __ April 26, 2013 __ August 30, 2013

__ ESL only __ ESL + undergraduate studies __ ESL + graduate studies __ ESL + college (see separate application)

Where did you learn about CultureWorks? __ Agent __ Friend/Family __ High school counselor __ Student fair __ Search engine __ CultureWorks website __ Other (please specify) ___________________ Partner Website: __ Kings __ Brescia __ Western __ UOIT __ Durham

ACCOMMODATIONS Will you require homestay/roomstay? Will you require residence? Will you require airport reception? __ yes __ yes __ yes __ no __ no __ no

Will you require medical insurance through CultureWorks? __ yes __ no If yes, will you require medical insurance for any family members? __ yes __ no If yes, please indicate the names and birthdates of those family members. __________________________________ Name __________________________________ Name __________________________________ DOB __________________________________ DOB If you are applying to university, please complete the rest of this form. Undergraduate Studies in London CHOOSE YOUR CAMPUS: Kings University College at Western University ____ Brescia University College at Western University (women only) ____ Western University (Main Campus) ____ Choose your program: Arts & Humanities __Classical Studies (Main only) __English Language & Literature __Film Studies (Main only) __French Language __Linguistics (Main only) __Media, Information & Technoculture (Main only) __Philosophy __Religious Studies (Kings/Brescia only) __Womens Studies & Feminist Research (Main only) Engineering (Main only) __Chemical Engineering __Civil Engineering __Computer Engineering __Electrical Engineering __Green Process Engineering __Integrated Engineering __Mechanical Engineering __Software Engineering Health Science __Community Rural Health Development (Brescia/Main only) __Health Science (Brescia/Main only) __Rehabilitation Sciences (Main only) Management & Organizational Studies __Accounting __Consumer Behaviour (Brescia only) __Finance & Administration (Kings/Main only) __Food Management (Brescia only) __Global Commerce (Kings only) __Management & Organizational Studies (Kings/ Main only) __Organizational & Human Resources (Kings/ Main only) Social Science __Anthropology (Main only) __Childhood & Social Institutions (Kings only) __Community Development (Brescia only) __Crime & Communities (Brescia only) __Dimensions of Leadership (Brescia only) __Economics (Kings/Main only) __Family Studies, Families & Communities, Nutrition & Families (Brescia only) __Geography (Main only) __History __International Relations (Main only) __Political Science __Psychology __Social Justice & Peace Studies (Kings only) __Social Work (Kings only) __Sociology

Science __Actuarial Science (Main only) __Astrophysics (Main only) __Biology (Main only) __Bioinformatics (Main only) __Chemistry (Main only) __Chemistry & Biochemistry (Main only) __Computer Science (Main only) __Earth & Planetary Science (Main only) __Environmental Science (Main only) __Foods & Nutrition (Brescia/Main only) __Food Science & Technology (Brescia/Main only) __Genetics (Main only) __Geology (Main only) __Information Systems (Main only) __Kinesiology (Brescia/Main only) __Mathematics (Main only) __Physics (Main only) __Physiology (Main only) __Statistics (Main only)

Preliminary Year* - Co-ed (Brescia only)

*Preliminary Year is a pre-university program for students who lack the admission requirements for first-year of university study.

Advanced Entry Opportunity* Honors Business Administration (Richard Ivey School of Business)
*Pre-admission status (for third year), must also apply to and meet the admission requirements of Western University:

www.ivey.uwo.ca

Western University - Graduate There are 75 graduate level programs offered at Western. Not all departments will offer conditional acceptance, nor do international students qualify for all programs. Please review the programs offered at the School of Graduate and Postdoctoral Studies website: http://grad.uwo.ca/prospective_students/programs.cfm Once you have decided on the program you wish to apply for, please contact Lauren Williams (Registrar) at: lauren.williams@cultureworkstheschool.com for further information. Undergraduate Studies in Oshawa University of Ontario Institute of Technology Please number (1, 2, 3) your top three choices: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Applied & Industrial Mathematics Automotive Engineering Biological Science Chemistry Commerce Communication Community Development Computing Science Criminology Digital Media Electrical Engineering Energy & the Environment Energy Systems Engineering Forensic Psychology Forensic Science Health Physics & Radiation Science Health Science __ Information Technology, Game Development & Entrepreneurship __ Information Technology, Networking & Security __ Kinesiology __ Legal Studies __ Life Sciences __ Manufacturing Engineering __ Mechanical Engineering __ Medical Laboratory Science __ Nuclear Engineering __ Nursing __ Pharmaceutical Chemistry __ Physical Science __ Physics __ Public & Social Policy __ Software Engineering

University of Ontario Institute of Technology - Graduate __ Applied Bioscience (Masters) __ Applied Bioscience (PhD) __ Automotive Engineering (Masters) __ Business Administration (MBA) __ Computer Engineering (Masters) __ Computer Engineering (PhD) __ Computer Science (Masters) __ Computer Science (PhD) __ Criminology (Masters) __ Education (Masters) __ Electrical Engineering (Masters) __ Electrical Engineering (PhD) __ Education & Digital Technologies (Graduate Diploma) Durham College There are numerous diploma and certificate programs offered at Durham College. Please contact Amanda Furnis (Registrar) at: amanda.furnis@cultureworkstheschool.com or visit our website: www.culture-works.com for the full application form. EDUCATIONAL BACKGROUND Highest level of education completed: High School or Secondary Education Name: _______________________________________________________ City: _____________________________________________________________ Country: ___________________________________________________________ From (month/year): _______________ To (month/year): _______________________________________________ Graduation certificate awarded __ Yes __ No Post-secondary Education (College/University) Name: ________________________________________________________________________ City: ________________________________________________________________________ Country: _________________________________________________________________ From (month/year): __________________________________________________________ To (month/year): __________________________________________________________ Program of study: __________________________________________________________ Diploma/degree awarded __ Yes __ No
By checking this box, I certify that I have disclosed all educational institutions I attended. During any period of time not accounted for, I was/am not in attendance at any educational schools. I understand that any misrepresentation of this information may result in the cancellation of my application, admission or registration at the University.

__ Health Sciences (Masters) __ Information Technology Security (Masters) __ Materials Science (Masters) __ Materials Science (PhD) __ Mechanical Engineering (Masters) __ Mechanical Engineering (PhD) __ Modelling & Computational Science (Masters) __ Modelling & Computational Science (PhD) __ Nuclear Engineering (Masters) __ Nuclear Engineering (PhD)

__________________High school__________________

______ _____________ Students Signature

________June 19, 2012__________ Date

(Mar/12)