Student Aid Alberta

Service Centre

REQUEST FOR REPLACEMENT

TO BE USED FOR CHEQUES THAT HAVE NOT BEEN CASHED

TO BE COMPLETED BY THE STUDENT

I , _________________________________________________, advise and declare:

Name of Student

1. THAT I am informed by Her Majesty the Queen in Right of Alberta as represented by the
Minister of Innovation and Advanced Education (the “Minister”) and do verily believe that the
Minister has issued a cheque in the amount of $«CHQAMT»and numbered «CHQNumber»
payable to me in favour of the Alberta Student Loan Program (the “Cheque”).

2. THAT I have not cashed the Cheque and the circumstances surrounding the failure to cash the
Cheque are as follows:
□ The cheque was not received.
[ J The cheque was lost or destroyed without being cashed.

3. THAT except as specifically stated above, neither the Cheque nor any interest therein has been
sold, assigned, endorsed, transferred, deposited under any agreements, hypothecated,
pawned, pledged to any bank or otherwise, or disposed of in any manner by me or on my
behalf.

4. THAT I have requested the Minister to replace the Cheque. If such request is granted, I
undertake to return the original Cheque number «CHQNumber» if found or received, uncashed
to:

Student Aid Alberta Service Centre

PO Box 4050
Mississauga STN A
Mississauga ON L5A 4M9

5. I further undertake to inform the Minister of any knowledge that I may acquire as to the
whereabouts of the original Cheque.

6. THAT I understand that if I make a false or misleading statement, I may be denied future
student aid and/or I may be required to immediately repay all financial assistance received
and/or I may be subjected to criminal prosecution.

Student's Signature Date

Witness Signature Date

Student Aid Alberta Service Centre

P.O.Box 4050 • Mississauga, STN A • Mississauga ON • L5A 4M9

E&OE AB-Disb-Indemnity Form(E)(vers 5.2)

Page 1
 Program Compliance & Investigations Social Insurance Number
PO Box 28000 Stn Main
Edmonton AB T5J 4R4
Tel: 780-427-5560 Fax: 780-422-0091
Student Aid Alberta
Accommodation Report
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of Information
and Protection o f Privacy Act (Alberta) to determine and verify the student’s/renter’s eligibility for financial assistance in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended from
time to time. This information may be verified or audited. The use and disclosure of your personal information is managed in accordance with the
Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call
the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid
Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.
Note: The information provided below will be used to determine your eligibility for accommodation costs. Please have your landlord or
property owner complete the information below. Once the form is completed, fill in your Social Insurance Number in the space
indicated above and submit the form to Student Aid Alberta, Program Compliance & Investigations (address above).
Renter’s Name (Please print)
Last Name First Name

Street Address or Legal Land Description of Property Mailing Address of Property (if different)
Apartment or Box Number_______________________________ Apartment or Box Number__________________

Street Street

Area Code Telephone

Type of Accommodation
ED House ED Apartment ED Mobile Home ED Room & Board ED Reserve Band Housing ED Other (specify),
Date Rented (day/month/year) Monthly Rent ($)

Are Utilities included in rent?

Gas? EDYes ED No Power? EDYes EDNo Water? EDYes EDNo Phone? EDYes EDNo
Is Accommodation Shared? EDYes EDNo
Total Number of adults who live in the unit Name(s)

Total Number of children who live in the unit Name(s)

Landlord or Authorized Agent

Last Name First Name Are you an adult re ative of the renter/boarder? EDYes EDNo
If yes, relationship:

Address
Apartment or Box Number Are you the owner of the residence? EDYes ED No

Street Province Postal Code

City/Town Area Code Telephone

Landlord or Authorized Agent’s Signature Date (day/month/year)

____I___ ____ I_______ I___ I I

Jan 2014
Page 2
 Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility, and if I do not want to be identified I will contact Alberta Scholarship Programs.

Signature of Applicant Today’s Date (in ink)

To be Completed by the Nominating Institution

NOMINEE’S SECONDARY EDUCATION

Name o f High School (before starting upgrading):

Date Last Attended High School: ___________ Highest Grade Com pleted:______

NOMINEE’S UPGRADING PROGRAM:

Nominated by:
Name of Institution

Average in upgrading program: ________________

Date nominee completed upgrading:__________________

Nominee meets the eligibility requirements: Yes Q No [

Name of Institution Official Signature of Official

Date:

Page 3
 ADULT HIGH SCHOOL EQUIVALENCY SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
information, please contact Alberta Scholarship Programs, 4th Floor-9940 106 Street, Edmonton, AB T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number (go to www.education.gov.ab.ca to find your ASN or to obtain one) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gcilder (circle one) Birthdate Email Address

M F month year
____ 1____ ____1____ 1____ 1____

CITIZENSHIP (check one)

□ CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.

ALBERTA RESIDENCY
Does one parent currently reside in Alberta? N Have you lived in Alberta all your life? N
IF YOU HAVE ANSWERED “ NO” TO BOTH QUESTIONS, If no, since nth
PLEASE INCLUDE A LETTER EXPLAINING THE TIM E YOU _L l i i
SPENT IN ALBERTA AS A NON FU LL -TIM E STUDENT.

PROPOSED POST-SECONDARY STUDIES

Name of Institution

Institution City Start Date for Program Program

month | year
I I I I I

Office Use Only

91 8 8 8 © 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

E
MO YR SFB AUTHORIZATION AWARD KEY APP KEY

Revised: April 2014

Page 4
 ADULT HIGH SCHOOL EQUIVALENCY SCHOLARSHIP

The Adult High School Equivalency Scholarship recognizes and rewards academic achievement in the attainment of high school
equivalency and provides an incentive for mature students to continue their education at the post-secondary level.

Award Amount - $500

Eligibility Criteria

A nominee must:

a. be a Canadian citizen or a Permanent Resident,

b. be an Alberta resident, and to to be considered an Alberta resident one of the following conditions must apply:
• one parent must currently be residing in Alberta, or
• Alberta is the last place the student has lived for twelve (12) consecutive months before being a full-time student, or
• is married to an Alberta resident before the start of the qualifying year of study.
c. have been out of high school for a minimum of three (3) years before starting a high school equivalency program,
d. have been enrolled full-time in a high school equivalency program in Alberta of at least one year in length,
e. achieved an academic average of 80% or a GPA of 3.5 or greater in their high school equivalency program, and
f. be enrolled or intending to enroll full-time in a post-secondary program after completing a high school equivalency
program.

Selection Procedures

Recipients are nominated by the Student Awards Office at the Alberta educational institution where they completed their high school
equivalency program.

Return completed application to the Student Awards Office at your educational institution.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Information on other awards administered by Alberta Scholarship Programs can be

obtained at:: alis.alberta.ca/scholarships

Nomination Deadline: September 1

Page 5
Adult High School
Equivalency
Scholarship
 Letter of Understanding for Private Scholarships/Awards

Name of Scholarship: China - Alberta Award for Excellence in Chinese

Objective: To recognize the achievement of a student who has demonstrated
excellence in their first year of a Chinese language and culture
program.
Value: $500 per award
Number of Awards Issued At least one award.
Annually:
Number of Years the 5 years initially, with review for extension
Scholarship will be
Awarded:
Where Tenable: At any public or private accredited school authority in Alberta.
Eligibility Criteria: The applicant must:
• be a Canadian Citizen or a permanent resident o f Canada
• be a resident o f Alberta
• have taken Chinese Language and Culture 10-3Y, 20-3 Y
and 30-3Y.
Applicants may only apply once for this program.
Recipients are eligible to receive other awards.
At least one o f the student’s parents must be an Alberta
resident.
Courses to be considered in determining academic success:
Minimum average o f 80% in all courses.
Minimum o f 90% in Chinese 10-3Y and 20-3Y.
Can only apply when they are presently in grade 12.
Application Deadline: June 30th
Application Procedure: Alberta Education will promote the program.
The application package and form will be available to download
online.
Only one application per eligible school will be accepted in any
given year.
The Selection Committee may elect to obtain supporting or
clarifying infonnation at any time before a final decision is made
on awardees.
Selection Process: The recipient will be selected by a committee of at least three
people designated by Alberta Education.
The committee will review each student’s marks, a 2 paragraph
essay on how will what you learned in the Chinese language and
culture program apply to your future studies/career and the
teacher’s and/or school’s recommendation.
The committee may, at their discretion, try to balance awards

Page 7

Disbursement of First
Award:
Donation
Is Tax Receipt Required?
Investment and Earnings
Other Considerations:
Fees
across the province.
The first award under this scholarship program will be issued in
the Fall of 2014.
$5,000 from Government of China
$5,000 from Government of Alberta
No
Awards will be open for future donations from government and/or
private business or individuals. Private contributions will be given
a tax receipt.
It is the intention for the program to grow to a point where interest
earned makes the program self-sustaining.
A report indicating the recipient each year and the value of the
scholarship will be presented to Alberta Education by June 1, each
year if required. Alberta Education can share this report with the
Government of China.
The Minister of Enterprise and Advanced Education retains final
authority over the award. However, the scholarship office may
consult with the donor regarding any possible future changes to the
scholarship. If the scholarship office has made three consecutive
unsuccessful attempts to contact the donor, the scholarship office
will cease trying to communicate with the donor and will make
independent decisions regarding the scholarship.
No Fee.

The conditions in this document have been thoroughly discussed with the donor. As indicated in
section 3(4) of the Alberta Heritage Scholarship Act, this donation is accepted by the Ministry of
Enterprise and Advanced Education as an unconditional gift for which the Minister may consider
direction from the donor. The Minister of Treasury Board and Finance has the authority over the
ongoing management of the scholarship fund.

Name of Signatory representing Signature of Ministry Date

the Ministry of Enterprise and Representative
Advanced Education

I understand and accept the conditions outlined in this document.

Name of Donor Signature of Donor Date

Selection Committee

Page 8
Note to administrator: At no time shall any current or future member o f the Selection
Committee be employed by a higher level secondary institution in Alberta as this would
be a conflict o f interest and/or not relevant to the commercial intent o f this scholarship.

1. Chief of Education Office in the Consulate-General o f The People’s Republic of

China in Vancouver. Contact info:
Education Office, Consulate-General o f
The People's Republic o f China in Vancouver
2215 Eddington Drive
Vancouver, B.C. Canada V6L 2E6
Tel:604-7326723
Fax:604-7381801
Website:http://www.chinaeduvan.org/

2. Chinese Advisor at Alberta Education. Contact info:

Special Language Advisor - China
International Education Services
Alberta Education
Main floor, 44 Capital Boulevard
10044 - 108 street,
Edmonton, Alberta, Canada T5J 5E6
Tel: 780-644-3063
Fax: 780-644-2284

3. Manager at International Education Services, Alberta Education.

4. Teacher representative from Alberta Schools

Page 9
 The Alberta Apprenticeship
and Industry Training Board
FAMILY OF SCHOLARSHIPS

The Alberta
Apprenticeship and Application
Deadline
Industry Training June 30, 2014
Scholarships

The Apprenticeship and Industry Training Scholarships are designed

to recognize the excellence of Alberta apprentices and trainees and to
encourage them to continue and complete their apprenticeship or
occupational training.

APPLICATION 2014

Apprenticeship
and Industry
Training
Government
Page 10
To apply, complete these steps

STEP 1: Make sure you are eligible.

You must:
• be a Canadian citizen or Permanent Resident, and a resident of Alberta as defined by Alberta Scholarship Programs,
• be a registered Alberta apprentice or a designated occupation trainee,
• determine how many periods of technical training are required for your trade or occupation and see sections A, B or C
on the following pages for important additional eligibility criteria.
• Section A: Criteria for trades with more than one period of technical training
• Section B: Criteria for trades with only one period of technical training
• Section C: Criteria for designated occupations

STEP 2: Fully complete the application form.

• Your application must be accompanied by a completed Employer Recommendation (form enclosed).
• Alberta Scholarship Programs will obtain your marks from your apprenticeship program. You do not need to attach
marks to this application.
• Your application must be complete. Incomplete applications will be removed from the selection process.
• Eligibility details and an electronic version of this application form can be found at tradesecrets.alberta.ca.

Please note: An Alberta Student Number (ASN) is mandatory to apply for

an Apprenticeship and Industry Training Scholarship. This applies to all applicants
regardless if you have previously attended school in Alberta or not.

If you do not know your ASN or need to have one assigned (if you moved to Alberta
from another province or country), visit the Learner Registry at education.alberta.ca or
call (780) 427-5318. Due to privacy issues, ASNs will not be given out over the phone.

STEP 3: Forms must be post-marked by June 30, 2014.

Faxes or E-mails will not be accepted.

Send your completed applications to:

Apprenticeship and Industry Training Scholarships

c/o Alberta Scholarship Programs
Box 28000 Station Main You will be notified of the
status of your application
Edmonton, Alberta T5J 4R4
by November 1,2014.

If you have any questions about the Alberta Apprenticeship and Industry Training Scholarships, please
contact Alberta Scholarship Programs at (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000)
or e-mail scholarships@gov.ab.ca.
Page 11
Step 1 Continued: Additional Eligibility Criteria
Section A
Trades with more than one period of technical training

You must:
• have attended apprenticeship technical training and passed your first or subsequent Alberta Apprenticeship
and Industry Training exam between July 1,2013 and June 30, 2014, and
• have at least one period of technical training remaining in your program.

Note: Apprentices in trades with only 2 periods of technical training who complete both periods of technical
training between July 1,2013 and June 30, 2014 are also eligible to apply for a scholarship. These trades
are marked with an asterisk (*) below.

TRADES & TRAD E N U M B E R

Agricultural Equipment Technician (032-1) Ironworker - Reinforcing (040-3)*
Appliance Service Technician (023) Ironworker - Structural/Ornamental (040-2)
Appliance Service Technician Landscape Gardener (047)
- Commercial Appliance Service Technician (023-1)* Lather-Interior Systems Mechanic (017)
Auto Body Technician (010) Locksmith (050)
Auto Body Technician - Auto Body Refinisher (010-3)* Machinist (015)
Auto Body Technician - Auto Body Repairer (010-2) Millwright (016)
Automotive Service Technician (009) Motorcycle Mechanic (049)
Baker (024) Natural Gas Compression Technician (053)
Boilermaker (038) Outdoor Power Equipment Technician
Bricklayer (001) - Power Equipment (051-5)
Cabinetmaker (036-1) Outdoor Power Equipment Technician
Carpenter (002) - Recreational Equipment (051-6)
Communication Technician (022) Painter and Decorator (004)
Concrete Finisher (048)* Parts Technician (0271)
Cook (018) Parts Technician - Materials Technician (0272)
Crane and Hoisting Equipment Operator Plumber (006)
- Mobile Crane (034-1)* Plumber and Gasfitter (006-1)
Electric Motor Systems Technician (030) Powerline Technician (021)
Electrician (003) Power System Electrician (046)
Floorcovering Installer (029)* Recreational Vehicle Service Technician (045-2)
Gasfitter (A) (008-1) Refrigeration and Air Conditioning Mechanic (014)
Gasfitter (B) (008-2)* Rig Technician (052-3)
Glazier (025) Roofer (028)
Glazier - Auto Glass Technician (025-2)* Sheet Metal Worker (011)
Hairstylist (042-1)* Sprinkler Systems Installer (037)
Heavy Equipment Technician (019-1) Steamfitter-Pipefitter (0074)
Heavy Equipment Technician Structural Steel and Plate Fitter (026)
- Heavy Duty Equipment Mechanic (Off Road) (019-2) Tilesetter (020)*
Heavy Equipment Technician Transport Refrigeration Technician (041)
- Truck and Transport Mechanic (019-3) Water Well Driller (035)*
Instrument Technician (031) Welder (012)
Insulator (033)
Ironworker (040)
Ironw orker- Metal Building Systems Erector (040-1)*

Page
The Alberta Apprenticeship and Industry Training Scholarships 2014
Step 1 Continued: Additional Eligibility Criteria
Section B
Trades with only one period of technical training
You must:
• have attended apprenticeship technical training and passed your Alberta Apprenticeship and Industry
Training exam between July 1,2013 and June 30, 2014.
TRADES & TRADE N U M B ER
Auto Body Technician - Auto Body Prepper (010-1)
Crane and Hoisting Equipment Operator
- Boom Truck (034-3)
Crane and Hoisting Equipment Operator
- Wellhead Boom Truck (034-4)
Section C
Designated Occupations
For the following designated occupations, you must have
passed your Alberta Apprenticeship and
Industry Training exam between July 1, 2013
and June 30, 2014:
Construction Craft Labourer (203)
Field Heat Treatment Technician (209)
Industrial Construction Crew Supervisor (208)
Residential Construction Site Manager (212)
Steel Detailer - Level 1 (204-1)
Steel Detailer - Level 2 (204-2)
Steel Detailer - Level 3 (204-3)
For the following designated occupation, you must
submit, with your application form, a notarized copy of
your NAIT Continuing Education Certificate - Gas Utility
Operator issued between July 1,2013
and June 30, 2014:
Gas Utility Operator (200)
Application Deadline: June 30, 2014
Heavy Equipment Technician
- Transport Trailer Mechanic (019-4)
Welder - Wire Process Operator (012-1)
For the following designated occupations, you must
submit, with your application form, a copy of your
Occupational Certificate issued between July 1,2013 and
June 30, 2014:
Oil and Gas Transportation Sen/ices
- Bed Truck Operator (206-3)
Oil and Gas Transportation Sen/ices
- Bulk Haul Truck Operator (206-4)
Oil and Gas Transportation Sen/ices
- Multi-Wheel Truck Operator (206-5)
Oil and Gas Transportation Sen/ices
- Supervisor (206-1)
Oil and Gas Transportation Sen/ices
- Swamper (206-2)
Oil and Gas Transportation Sen/ices
- Winch Tractor Operator (206-6)
Snubbing Services - Assistant Operator (207-1)
Snubbing Services - Operator 1 (207-2)
Snubbing Services - Operator 2 (207-3)
Snubbing Services - Operator 3 (207-4)
Snubbing Services - Supervisor 1 (207-5)
Snubbing Services - Supervisor 2 (207-6)
Well Testing Services Supervisor - Level 3 (205-1)
Well Testing Services Supervisor - Level 4 (205-2)
Well Testing Services Supervisor - Level 5 (205-3)
Page 13
Application for Alberta Apprenticeship N76
and Industry Training Scholarships 2014
Incom plete applications will be deem ed ineligible and will be rem oved from the selection process.
We are collecting personal information in this application under the authority o f section 33(c) o f the Freedom o f Information and Protection o f Privacy Act,
c. F-25, FISA 2000 to determine and verify your eligibility for an Alberta Apprenticeship and Industry Training Scholarship under the Alberta Fieritage
Scholarship Act, c. A-24, FtSA 2000 and for research and statistical purposes. If you have any questions about the collection o f this information, you can
contact the Director, Alberta Scholarship Programs, 4th Floor, 9940 - 106 Street, Edmonton, Alberta, T5K 2V1 Phone: (780) 427-8640.

(Please print legibly using blue or black ink)

Alberta Student Number

Apprentice I.D. Number

(Trade No.) (Apprentice I.D.

Gender EHMale □ Female Birth date

(please check one) day m o n th ye a r

Designated Trade/Occupation_____________

Last Name First Name

Mailing Address

City/Town Province Postal Code

Telephone Number

Email --------------------------------------------------------------------------------

When did you complete your last period or level of technical training?
m o n th ye a r

Where did you complete your last period or level of technical training?

Have you registered for your next period of technical training? (please check one) D Y es □ No

If yes, where?

Continued on reverse

Page 14
The Alberta Apprenticeship and Industry Training Scholarships 2014 Page 1
Tell Us About Yourself
To be considered for a scholarship you must include one or two paragraphs telling us about yourself. Include what
you enjoy about your trade or occupation, why you chose this career and how this scholarship will benefit you. Feel
I
free to use additional or typewritten sheets as required. Please write legibly or attach a typed description about
yourself.
Your written comments are very important to your evaluation for a scholarship.
I
I
I
____________________________________________________________________________________________________________ I
I

------------------------------------------------------------------------------------------------------------------------------------------------------------------- I

I
I
I
I
I
I

I
I
I
I
I
I
i
Page 15
The Alberta Apprenticeship and Industry Training Scholarships 2014 Page 2
 Employer N76
TEAR HERE

Recommendation
Alberta Apprenticeship and Industry Training Scholarship Application
Please type or print legibly.

NOTE TO APPRENTICE: Print your name and trade in this section before giving this form to your employer,
supervisor or supervising certified tradesperson.

Applicant’s Name

Apprentice I.D. Number

Designated Trade/Occupation

NOTE TO THE EMPLOYER OR PERSON AUTHORIZED ON BEHALF OF THE EMPLOYER TO COMPLETE THIS
FORM (SUPERVISOR OR SUPERVISING CERTIFIED TRADESPERSON):

Your assessment of this apprentice is an important component in the scholarship selection process and must be
submitted prior to June 30, 2014 for the apprentice to be considered for a scholarship.

The Apprenticeship and Industry Training Scholarships are designed to recognize the excellence of Alberta apprentices
and trainees and to encourage them to continue and complete their apprenticeship or occupational training.

Please complete the following information regarding the applicant:

This apprentice has worked for me a total of months.

1. In your opinion, is this individual deserving of an Alberta Apprenticeship and Industry Training Scholarship?

□ Yes □ No*

2. In your opinion, does this individual meet or exceed safe work practices?

□ Yes □ No*

3. Why is this apprentice an outstanding candidate for an Alberta Apprenticeship and Industry Training Scholarship?
Your written comments are also very important to the evaluation of this apprentice. Use additional sheets if necessary.
Please include comments on some of the following: punctuality, work relationships, attitude, attendance, willingness to
learn and/or representation of self, employer and jobsite.

‘ Please note: Applicants that receive a “No” for either questions 1 or 2 are NOT eligible for a scholarship.

Page 16
The Alberta Apprenticeship and Industry Training Scholarships 2014
Employer

TEAR HERE
Recommendation
Dates apprentice employed with company: To OR □ check box if still employed
Please type or print legibly. day m o n th ye ar day m o n th ye a r with the company

Full Company Name

Address

City/Town Province | Postal Code —

Telephone — —

Email

Name of person completing this form (please print)

Position of person completing this form: Employer □ Supervisor □ Certified Tradesperson □

Signature
day m o n th

This form may be returned to the apprentice or designated occupation trainee to be mailed with their completed
scholarship application OR mailed directly to the following address:

Apprenticeship and Industry Training Board Scholarships

c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Telephone: (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000)

Please complete and sign this two-page Employer

Recommendation form and submit it before June 30, 2014.

Page 17
The Alberta Apprenticeship and Industry Training Scholarships 2014
 Residency
Citizenship (please check) □ Canadian Citizen □ Permanent Resident

NOTE: If you are a Permanent Resident, you must include a photocopy of your permanent resident card or immigration long form.
Visa students are ineligible.

Have you lived in Alberta all your life? (please check) □ yes □ No If no since
day m o n th year

Do your parents live in Alberta? (please check) □ Yes □ No

Aboriginal Scholarships
Some scholarships are designated for apprentices of Aboriginal descent. If you are Aboriginal and wish to be considered for one of
these scholarships, you must complete this section. If you choose not to complete this section, your application will still be considered
for those scholarships not specific to Aboriginal apprentices.

Aboriginal, as defined by the Canadian Constitution: ‘Aboriginal peoples of Canada” includes the Indian, Inuit and Metis peoples of Canada.
Are you of Aboriginal descent? (check) O Yes Q No
If yes, please complete the following. Are you:

□ Indian: Which First Nation? _____________________________________________________________________________________

□ Metis: Which Metis Settlement or Zone?__________________________________________________________________________

□ Inuit: Where were you born? _____________________________________________________________________________________

NOTE: Applicants selected to receive an Aboriginal scholarship may be required to provide documentation verifying their status as an Aboriginal person.

If you have questions about the Alberta Apprenticeship and Industry Training Scholarships, please contact Alberta Scholarship
Programs at (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000), or email scholarships@gov.ab.ca.

Page 18
The Alberta Apprenticeship and Industry Training Scholarships 2014 Page 3
 Declaration and Authorization
I have read the instructions and hereby make an application for an Alberta Apprenticeship and Industry Training Scholarship.

I DECLARE:
• I have answered all the questions applicable to me and all the information is true and complete and subject to audit.
• I plan to continue as an apprentice in my trade or as trainee in my occupation.
• I will notify the office of Alberta Scholarship Programs if I withdraw from my apprenticeship or occupational training program
before completion.

I AUTHORIZE:
• Alberta Scholarship Programs to request and receive my marks and other information about my apprenticeship program such as
name of the institution I am attending and my period of technical training, from Alberta Apprenticeship and Industry Training for the
purpose of determining my eligibility for a scholarship. I also authorize Alberta Apprenticeship and Industry Training to disclose this
information to Alberta Scholarship Programs.
• Alberta Scholarship Programs to request and receive from the post-secondary institution I am attending, information pertaining to
my enrollment status for the purpose of determining my eligibility for a scholarship. I also authorize my post-secondary institution
to disclose this information to Alberta Scholarship Programs.
• Alberta Innovation and Advanced Education to provide my information to other funding agencies in Canada such as non-profit
organizations, industry associations, private donors, municipal, provincial or federal governments, so that I may be considered for
any other apprenticeship scholarships for which I may be eligible, in which case all the information, consents, authorizations and
declarations made in this application apply to any such other apprenticeship scholarship for which I may be considered.

If I am awarded a scholarship, I AUTHORIZE:

• Alberta Innovation and Advanced Education, or its representative, to publish my name, city/town, name of employer, trade,
institution, name of scholarship awarded and photograph for publicity purposes,
• Alberta Innovation and Advanced Education to provide my name and contact information, trade, year or period of training and
the name of my employer, to the sponsor of my scholarship, to any agency wishing to recognize the award, to local MLA offices
and to any interested media wishing to contact me for the purpose of an interview.

SIGNATURE OF APPLICANT
day m o n th year
PRINT NAME ___________

Mail completed applications to: Apprenticeship and Industry Training Scholarships

c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

You will be notified of the status of your application by November 1,2014.

Page 19
The Alberta Apprenticeship and Industry Training Scholarships 2014 Page 4
Selection
A committee made up of members of the Alberta Apprenticeship and Industry Training Board will select recipients.
Recipients will be selected based on marks, Employer Recommendation and personal description. You will be notified of
the status of your application by November 1,2014. Apprentices will only be selected for a maximum of one scholarship
each year within the Alberta Apprenticeship and Industry Training Board Family of Scholarships.

Double check your application! Have you:

□ answered all of the questions and checked all of the
appropriate boxes in a neat and legible manner?

□ included your apprentice I.D. number? Mail completed applications to:

□ completed the residency section and if needed, Apprenticeship and Industry Training Scholarships
attached a photocopy of proof of residency? c/o Alberta Scholarship Programs
Box 28000 Station Main
□ included the completed employer recommendation
form? (or your employer can mail it separately) Edmonton, Alberta T5J 4R4

□ signed the form?

Please Note

• Alberta Scholarship Programs will obtain your marks from your apprenticeship program. You do not need
to attach marks to this application.

• You will be notified of the status of your application by November 1,2014.

• Only technical training that is part of an approved apprenticeship program will be recognized for
payment of an award. A list of approved programs can be found in the Technical Training Centre on
tradesecrets.alberta.ca/learn-on-the-job.

• If you are challenging the technical training exam you will not be considered enrolled in technical training and
therefore will not be eligible to apply for or receive a scholarship.

• Scholarship cheques will be mailed to recipients when they have begun their next period of technical training
(some exceptions apply). Instructions will be sent to you in the scholarship recipient package, if you are selected.

• Recipients must qualify for, and claim, their scholarship within five years of being notified of their award.

• Complete eligibility details can be found at tradesecrets.alberta.ca

Page 20
Scholarship Donors
Major contributors from
the private sector are able
to name their scholarship.
These scholarship donors
are listed below.
• Aaron Drilling Ltd. (1)
• Adolf & Vally Klingbeil (2)
• Alberta Bricklayers Unions
Edmonton and Calgary (1)
• Alberta Construction Association/
Thygesen Family (32)
• Alberta Construction Safety
Association (1)
• Alberta Food Processors
Association (1)
• Alberta Glass (2)
• Alberta Interior Systems
Contractors Association (1)
• Alberta Ironworkers Apprenticeship
and Training Plan (7)
• Alberta-Pacific Forest
Industries Inc. (1)
• Alggin Metal Industries Ltd. (1)
• Amelco Electric (Calgary) Ltd. (1)
• Andrew G Clark Family (1)
• American Welding Society
Alberta Section (1)
• Architectural Woodwork
Manufacturers Association of
Canada - Southern Alberta
Chapter (2)
• Arpi’s Industries Ltd. (1)
• Arpi’s North Inc. (1)
• ATCO Power Ltd. (1)
Visit tradesecrets.alberta.ca for more information on the major private sector contributions
• Athabasca Oil Sands Project,
(a joint venture among Shell
Canada, Chevron Canada, and
Marathon Oil Sands L.P.) (10)
• Bird Construction Company (1)
• Black & McDonald Ltd. (1)
• Boilermaker Apprenticeship
Administration Agency (1)
• Botting & Associates Alberta Ltd. (2)
• Broadmoor Auto Body Ltd. -
Sherwood Park (1)
• Building Trades of Alberta (8)
• Building Trades of Alberta and
Construction Labour Relations-
An Alberta Association (2)
• Building Trades of Alberta,
Boilermakers Construction
Association, International
Brotherhood of Boilermakers,
KBR (Canada) Ltd.,
Syncrude Canada Ltd. (1)
• Bunch Welding Ltd. (2)
• Calgary Construction
Association (25)
• Calgary Motor Dealers
Association (3)
• Canadian Home Builders’
Association - Alberta (1)
• Canadian Institute of Steel
Construction - Alberta Region (1)
• Canadian Natural Resources Ltd. (1)
• Canadian Welding Association -
Edmonton Chapter (1)
• Canem Systems Ltd. (2)
• Canyon Plumbing & Heating Ltd. (1)
• Capital Power Corporation (2)
• Centaur Subaru (3)
• Charlton & Hill Ltd. (3)
• Chemco Electrical
Contractors Ltd. (1)
• CLAC (4)
• Clark Builders (2)
• Clearwater Welding &
Fabricating Ltd. (1)
• Compass Group (1)
• Comstock Canada Ltd. (1)
• Construction Labour Relations -
An Alberta Association (8)
• Construction Labour Relations -
An Alberta Association and
Mechanical Contractors
Association of Alberta - and
Alberta Southern (1)
• Construction Owners
Association of Alberta (5)
• CWB Group (1)
• Don Wheaton Ltd. (1)
• Eastside Dodge Chrysler Ltd. (1)
• Edmonton Construction
Association (50)
• Edmonton Construction
Association/Thygesen Family (5)
• Edmonton Motor Dealers’
Association (1)
• Edmonton Pipe Trades
United Association (1)
• Edwards Garage Ltd. (1)
• Electrical Contractors Association
of Alberta (2)
• Electrical Contractors Association
of Alberta and IBEW Local #424 (1)
• EnCana Corporation (1)
• Eskimo Steel Ltd. (1)
Page 21
• ExxonMobil Canada Ltd. (1)
• Ferguson Glass Western Ltd. (3)
• First Canadian Insurance
Corporation (1)
• Fluor Constructors Canada Ltd. (3)
• Flynn Canada Ltd. (1)
• General Presidents’ Maintenance
Committee for Canada (2)
• Gerald P Clark Family (1)
• Glass & Architectural Metals
Association (1)
• Glenmore Audi (1)
• Grande Prairie Auto Dealers
Association (1)
• Grayco Machine Ltd. (1)
• Heninger Toyota (2)
• Industrial Contractors
Association of Canada (2)
• Insulators’ Training
Trust Fund of Alberta (2)
• Ironworkers Local #720 (1)
• ISA Edmonton Section (1)
• Joe and Nancy Thompson
Family Foundation (1)
• JV Driver Projects Inc. (1)
• K. Hansen Masonry (1)
• KBR (Canada) Ltd. (1)
• Kramer Mazda (1)
• Ledcor Group (2)
• Lehigh Inland Cement Limited (1)
• Lexus of Calgary / Stampede
Toyota (1)
• Lockerbie & Hole Inc. (1)
• Manuel and Marion Dabrowski (1)
• Masonry Contractors
Association of Alberta (2)
Application Deadline June 30, 2014
• Mechanical Contractors • Sheet Metal Contractors
Association of Alberta - and Association of Alberta (1)
Alberta Southern (7)
• Sheet Metal Workers International
• Medicine Hat Construction Association Local #8 (2)
Association (1)
• Shell Canada Ltd. (1)
• Merit Contractors Association (7)
• Sherwood Park Optimist Club (2)
• Motor Dealers’ Association
• Sinclair Supply Ltd. (5)
of Alberta (8)
• Spartan Controls Ltd. (1)
• Muth Electrical Management Inc. (2)
• Suncor Energy (5)
• Neumann Plumbing ‘79 Ltd.(1)
• Supreme Steel Ltd. (3)
• Northern Alberta
Architectural Woodwork • Syncrude Canada Ltd. (4)
Manufacturers Association (1)
• Tarpon Energy Services (3)
• Pacific Western
• Thermal Insulation
Transportation Ltd. (1)
Association of Alberta (1)
• Park Derochie Coatings Ltd. (1)
• Tower Chrysler Plymouth Ltd. (2)
• PCL Construction Group Inc. (6)
• TransCanada Pipelines Limited (1)
• Pla-Son Holdings &
• Trimen Electric Ltd. (1)
Comfort Heating (1981) Ltd. (1)
• Trotter & Morton Ltd. (1)
• Progressive Contractors
Association of Canada (10) • U.A. Local #496/ Piping Industry
Training School (1)
• Provincial Glaziers
Association of Alberta (1) • United Association of Plumbers
& Pipefitters Local #488 (2)
• Quinn Contracting Ltd. (1)
• Vets Sheet Metal Ltd. (3)
• Ray-Nor Painting &
Decorating Ltd. (1) • Vulcan International (1)
• Red Deer Construction • W. Pidhirney Welding (1)
Association (1)
• Waiward Steel Fabricators Ltd. (3)
• Refrigeration and Air
• Watson Family (1)
Conditioning Contractors
Association of Alberta (1) • Willard Kirkpatrick (4)
• Roger Dootson Family (3) • Wirtanen Family Holdings Ltd. (3)
• S.E. Johnson Management Ltd. (1)
• Schendel Mechanical
Contracting Ltd. (1)
• Scotiabank Dealer Finance
Centre (1)
• Service Experts, a division
of Lennox Canada Inc. (1)
Page 22
 The Alberta Apprenticeship and Industry Training Board, in
partnership with industry and the Government of Alberta
Apprenticeship created the Alberta Apprenticeship and Industry Training
and Industry Board Family of Scholarships.
Training
The Board’s Family of Scholarships includes the Alberta
Apprenticeship and Industry Training (AIT) Board
Alberta Apprenticeship Scholarships, Top Apprentice Scholarships, Pre-Apprentice
Scholarships and the Registered Apprenticeship Program
and Industry Training (RAP) Scholarships.

Board The funds for the AIT scholarships are provided by joint
Family of contributions from the private sector and the Alberta Heritage
Scholarship Fund. A list of industry sponsors are included in
Scholarships this application. Each AIT scholarship is valued at $1,000.

The Government of Alberta is committed to encouraging

and rewarding the excellence of Alberta students. To this
end, the government offers scholarships through the
Achievement Scholarship Program and the Alberta
Heritage Scholarship Fund.

Further information about Government of Alberta

scholarships can be obtained on the Internet at:
alis.alberta.ca/scholarships

Alberta or by contacting:
Alberta Scholarship Programs
Box 28000 Station Main
Scholarship Edmonton, Alberta T5J 4R4
Telephone (780) 427-8640 (to be connected
Programs toll-free in Alberta, first dial 310-0000)

scholarships@gov.ab.ca

Page 23
 N O M I N A T I O N F O R

Alberta
Citizenship Awards

Page 24
 ALBERTA CITIZENSHIP AWARDS
The Province of Alberta offers three citizenship awards in recognition of students who support and contribute to Alberta
communities through public service and volunteer endeavours in school sponsored, community or extracurricular activities.

The three awards arc:

Premier’s Citizenship Award - One award plaque for a student in each Alberta high school
Queen’s Golden Jubilee Citizenship Medal - Eight awards of $5,000 and a medal presented by the Lieutenant Governor
Alberta Centennial Awards - Tweny-five awards of $2,005 each

r Eligibility Criteria
" \

Nominees for an Alberta Citizenship Award must be:

• Alberta residents, and
• Graduating from high school in the current academic year.

Nominees must have displayed outstanding characteristics in:

• Citizenship,
• Leadership,
• Community service, volunteer work, and must also have shown initiative and had a
positive impact in the community and/or school.
Please note: Academic achievement is not a requirement fo r these awards.
J
Selection Procedure
Premier’s Citizenship Award: Each Alberta high school selects one recipient. Recipients are also eligible for the Queen’s Golden
Jubilee Citizenship Medal and the Alberta Centennial Award. Please allow four weeks for processing.

Queen’s Golden Jubilee Citizenship Medal and Alberta Centennial Aw ard: From the pool of nominations for a Premier’s
Citizenship Award, a selection committee will select the top eight students to receive a Queen’s Golden Jubilee Citizenship Medal
and $5,000; and the committee will also select twenty-five recipients for an Alberta Centennial Award in the amount of $2,005.

In order to consider nominees for both the Queen’s Golden Jubilee Citizenship Medal and the Alberta Centennial Award,
nominations must be submitted to Alberta Scholarship Programs by June 1. Recipients are notified in February.

Completing the Nomination Form

To be considered for Alberta Citizenship Awards, students must complete the Personal Information and Declaration Sections and
submit this form to the selection committee at their school. The school’s selection committee chooses a recipient for the Premier’s
Citizenship Award, and the school principal completes the School Principal Section. If the school’s selection committee feels their
nominee should be considered for either the Queen’s Golden Jubilee Citizenship Medal or the Alberta Centennial Award, two letters
of reference must be submitted - further details are provided on the application.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB T5K2V1

Telephone: 780.427.8640
E-mail: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

The Premier’s Citizenship Award plaque is mailed directly to the high school.
Please allow' a minimum of four weeks for processing.
Plaques are not mailed during July or August.
 Queen’s Golden Jubilee Citizenship Medal
and Alberta Centennial Award

Selection Process
A selection committee established jointly by Alberta Culture and Alberta Innovation and Advanced Education
will select recipients for both the Queen’s Golden Jubilee Citizenship Medal and the Alberta Centennial Award.
Recipients for these two awards are selected from the pool of recipients for the Premier’s Citizenship Award.

Recipients of the Queen’s Golden Jubilee Citizenship Medal, will be presented with a medal by the Lieutenant
Governor, and receive a $5,000 award for future educational, cultural or language development opportunities.
Recipients of an Alberta Centennial Award will receive $2,005 and must be pursuing full-time studies in a post­
secondary program in the upcoming fall or winter term.

Academic achievement is not a requirement for these awards.

Only the successful candidates will be notified, usually in early February.

Selection Procedure
To be considered for one of the above awards, two letters of reference and a record of accomplishments must
accompany the school’s nomination for a Premier’s Citizenship Award.
Submit the nomination to Alberta Scholarship Programs by June 1.

References
Please attach two letters of reference: one reference letter should be from someone who has known the
candidate for at least one year, either through school or through community or volunteer activities. The second
letter of reference should be from a person who knows the candidate well enough to support and/or elaborate on
the candidate's activities and initiatives as outlined in the “Record of Accomplishments” chart.

It is preferable that the chart be completed by the student, and it is important that it be supported by one of the
reference letters.

Reference letters should be no more than two pages.

Page 26
 Record of Accomplishments

The chart below, preferably, should be completed by the student and outline accomplishments while in school and out
of school. It should be supported by one of the reference letters and cover the following areas:

Citizenship as demonstrated through involvement in the political process, e.g. student government, municipal,
provincial, or federal level;

Community Service and Volunteer Engagement, activities participated in, not mandated by the student’s program of
study or courses;

Leadership; led or started various activities, influenced others, made changes, etc.

Accomplishments should be limited to activities while in senior high school. The information should be three pages or
less and created in the sample format below. The chart should be verified by one of the referees or school principal or
school counsellor.

This form along with two reference letters will allow the committee to compare each candidate’s accomplisments and
evaluate the candidate’s role, results and impact of that activity, and level of involvement.

For each Grade Level, please follow the format outlined below:

Grade: __________
Citizenship Level of Involvement

Activity Role Results/lmpact Hours/Month No. of Months

C om m unity Service/Volunteer Engagem ent Level of Involvement

Activity Role Results/lmpact Hours/Month No. of Months

Leadership Level of Involvement

Activity Role Results/lmpact Hours/Month No. of Months

Grade The Grade the student was in when participating in the activity or project.
Activity Briefly describe the activity or project.
Role The student’s role in the activity, e.g. did the student lead, initiate, participate or
organize?
Results/lmpact The result of the activity, e.g. what was accomplished? The impact of the activity
e.g. did the student’s participation make a difference, would the activity have taken
place without the student’s participation? Will the activity or project continue after
the candidate has left high school?
Level of What was the extent of the candidate’s involvement, e.g. is the candidate passionate
Involvement activity? How much time and effort did the student devote to the activity or
project?

Page 27
 ALBERTA CITIZENSHIP AWARDS

Under the Freedom of Information and Protection of Privacy Act we arc required to advise you this information is necessary to
determine your eligibility for an award under the Queen Elizabeth II Golden Jubilee Recognition Act, Section 5. If you have any
questions about the collection of this information you can contact Alberta Scholarship Programs: 4th Floor, 9940 106 Street,
Edmonton, Alberta T5K 2V1, Phone: 780.427.8640.

Personal Information

Alberta Student Number Social Insurance Number (required for processing) High School Code

Mailing Address (include Apt. or Box Number) City/Town

CITIZENSHIP (check one) ALBERTA RESIDENCY

CANADIAN CITIZEN OR Do your parents currently live in Alberta? (circle one)
PERMANENT RESIDENT (Landed Immigrant) N If“No”, please include a letter
Note: Include a photocopy of permanent resident card. explaining where your parents
Visa students arc not eligible. currently reside.

Gender (circle one) Birthdate (Day. M onth, Year) E-Mail Address

M F
i l i ___I___ I___ I___

Revised: January 2014

Page 28
 Declaration of Nominee
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. to the best of my knowledge, the information provided in the application is true,

b. I grant permission for Alberta Scholarship Programs to request and receive information
pertaining to my academic performance and my post-secondary enrolment status,
c. I agree to fulfill the commitments of any award made pursuant to this application,
d. I authorize the release and exchange of personal information by and betweefr-Alberta
Scholarship Programs and any federal and provincial government departments, boards or
institutions to verify the information I have provided and for the use in research and
statistical analysis in program evaluation and
e. if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want to
be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

r a
To be Completed by the School Principal
I hereby declare that the nominee named herein is currently a student in good standing at this school and is our
sole nominee for the current school year 2014:

Name o f Principal Signature

Name o f School Date

Reminder:
The Premier’s Citizenship Plaque will be sent to the school approximately one month after the receipt o f the
nomination. Please ensure the nomination is submitted to Alberta Scholarship Programs at least four weeks
before any awards ceremony. NB: Plaques are not mailed to the school during July or August.

In order to be considered for the Queen’s Jubilee Citizenship Medal and the Alberta Centennial Award the
completed nomination form must be mailed to Alberta Scholarship Programs by June 1.

J
 Innovation and Agreement N um ber
Advanced Education agreement number

MEMORANDUM OF AGREEMENT
Alberta Institution Designation Agreement

This Memorandum of Agreement is made on , 20__.

BETWEEN:

HER MAJESTY THE QUEEN IN RIGHT OF ALBERTA

as represented by the Minister of Innovation and Advanced Education
(“Minister”)

- and -

Legal Name of Private Vocational Institution {if Incorporated} OR

Owner’s Legal Name, operating as Name of Private Vocational Institution {if using a Trade
Name}
(“Legal Owner”)

WHEREAS Alberta administers financial assistance programs for post-secondary students in accordance
with the Alberta Student Financial Assistance Act, as amended, and in accordance with agreements under
the Canada Student Loans Act and Canada Student Financial Assistance Act;

AND WHEREAS the provision of financial assistance to private vocational institution students is
contingent upon the institution meeting the requirements set out in Schedule 2 of the Alberta Student
Financial Assistance Regulation',

AND WHEREAS the Government of Alberta’s policy dealing with the designation of private vocational
institutions for financial assistance is designed to strengthen consumer protection, encourage student
choice, protect program integrity, and increase repayment rates on student loans;

AND WHEREAS the Government of Alberta is committed to providing personnel for consultation and
support to post-secondary institutions in the development and evaluation of administrative processes that
promote student success. This includes the distribution of materials that outline students’ rights and
responsibilities in repayment, programs that are available to students who are experiencing financial
difficulties, and administrative materials for schools;

AND WHEREAS the post-secondary institutions and personnel are expected to focus on student success,
including strategies to retain students and supports that improve their overall employability.

IN CONSIDERATION OF the Minister providing financial assistance to students registered in

programs of study offered by Name of Institution_________ (“Institution”) that are licensed under
the Private Vocational Training Act, the Legal Owner therefore agrees to the following:

June 2009. Legislative Services Branch - 1-

Page 30
 Innovation and Agreement N um ber
Advanced Education agreement number

1. The Legal Owner will comply with and adhere to all applicable provisions of the Canada Student
Financial Assistance Act, the Alberta Student Financial Assistance Act, the Private Vocational
Training Act, the Freedom of Information and Protection of Privacy Act and associated
regulations, policies and procedures, as amended from time to time.

2. The Legal Owner acknowledges that any information and records maintained or exchanged under
this Agreement may be subject to the privacy and access provisions of the Freedom of
Information and Protection o f Privacy Act. Should the Minister receive a request for any of those
records, the Legal Owner shall forward the records, at the Legal Owner’s expense, to the Minister
within 5 business days from the official notification by the Minister. The Legal Owner agrees to
retain all such records for at least one year after this Agreement expires or is terminated

3. The Legal Owner shall not, in its advertising dealing with vocational training,

(a) make reference to the fact that funding has been or may be issued to the Institution’s
students by the Minister as a recruiting tool, or

(b) refer to the Minister, the Government of Alberta or any department of the Government of
Alberta other than by the use of the words “vocational training licensed under the Private
Vocational Training Act”

unless the advertisement is approved by the Minister.

4. The Legal Owner will define and publish its tuition refund policy with respect to its licensed
programs as set out in the Private Vocational Training Regulation in applicable official school
materials, such as student handbooks, application packages and/or student contracts.

5. The Legal Owner will provide information concerning a student’s academic performance and/or
mailing address when requested by the Minister, and will ensure that it has the necessary
authority to do so in accordance with the Alberta Freedom of Information and Protection of
Privacy Act. Upon providing this information to the Minister, the Minister shall ensure that said
information is handled in accordance with the requirements of Freedom of Information and
Protection of Privacy Act and applicable policies and guidelines dealing with the protection of
personal information.

If a student withdraws from full-time studies or changes to part-time studies, as defined by the
Canada Student Financial Assistance Regulation and Alberta Student Financial Assistance
Regulation, the Legal Owner:

(a) will notify the Minister of the date of withdrawal or change to part-time studies in
accordance with “The Withdrawal From Full Time Studies” section of the “Educational
Institution Procedures” manual.

(b) will refund any unused portion of tuition calculated in accordance with the requirements
of the Private Vocational Training Regulation to the service provider holding the
student’s loan, within 30 business days of the date of withdrawal in accordance with the
requirements of the Private Vocational Training Regulation in the manner set out in the
Institution’s procedures manual,

June 2009. Legislative Services Branch -2 -

Page 31
 Innovation and Agreement N um ber
Advanced Education agreement number

(c) If the student does not attend classes for 5 consecutive business days and has not notified
the Institution of his or her withdrawal, the Institution will consider the student as having
withdrawn effective the first day of absence and shall notify the Minister in accordance
with this section.

The Legal Owner will provide the Minister with the names and sample signatures of staff that are
responsible for confirming registration, signing cheque registers, or signing loan documents, and
sample signatures of those authorized to sign on their behalf, as outlined in Schedule A which
forms part of this Agreement. The Legal Owner is responsible for all activities of these signing
authorities as they pertain to the performance of this Agreement and the provision of student
financial assistance in accordance with the Canada Student Financial Assistance Act, Alberta
Student Financial Assistance Act, the Private Vocational Training Act, the Freedom of
Information and Protection o f Privacy Act and their associated regulations, policies and
procedures as amended from time to time. The Legal Owner must, immediately prior to
revocation, advise the Minister, in writing, of the names of those persons whose signing authority
is revoked and the date upon which such revocation becomes effective.

8. The Legal Owner will allow the Minister’s staff on its premises and will cooperate with them, for
the purpose of an audit of all the Institution’s records to determine its compliance with this
Agreement, the Canada Student Financial Assistance Act, the Alberta Student Financial
Assistance Act, the Freedom o f Information and Protection of Privacy Act and their associated
regulations, policies and procedures, as amended from lime to time.

9. The Legal Owner may be required to reimburse the Minister for the reasonable cost of any audit,
including a forensic audit that the Minister may deem necessary for accountability purposes and
where the Legal Owner is found to be in breach of the Private Vocational Training Act, but not
including routine compliance audits.

10. The Minister may limit, withdraw or refuse to provide financial assistance to students registered
in courses of study or programs at the Institution if, in the opinion of the Minister,

(a) the loan repayment rate of the Institution’s former students is not maintained at an
acceptable level;

(b) the employment placement rate of the Institution’s graduates and/or the graduation rate of
students registered in the Institution is not maintained at an acceptable level;

(c) some of the practices or activities carried on by the Institution are not outlined in or are
contrary to the student enrollment contract, published rules and regulations and/or stated
policies of the Institution;

(d) that such action is necessary for the proper administration of the student financial
assistance program such as withdrawal of financial assistance for a program on an
industry-wide basis; or

(e) the Institution fails to comply with this Agreement.

June 2009. Legislative Services Branch -3 -

Page 32
 Innovation and Agreement N um ber
Advanced Education agreement number

11. The Parties, including their respective employees, agents and subcontractors, shall treat any
information acquired, disclosed or exchanged as a result of this Agreement in strict confidence
and with the care and security required to ensure that this information is not disclosed or made
known to any person except in accordance with the requirements of the Alberta Freedom of
Information and Protection o f Privacy Act.

12. The Legal Owner agrees to hold harmless the Minister from any and all third party claims,
demands, actions or costs (including legal costs on a solicitor-client basis) for which it is legally
responsible, including those arising out of negligence or willful acts by the Legal Owner, its
employees or agents.

13. The Legal Owner shall, at its own expense and without limiting its liabilities herein, insure its
operations under a contract of General Liability Insurance, in accordance with the Alberta
Insurance Act, 1999 cI-3, in an amount not less than $2,000,000.00 inclusive per occurrence,
insuring against bodily injury, personal injury and property damage including loss of use thereof.
Evidence of such insurance, in a format acceptable to the Minister, shall be made available upon
request.

14. This Agreement is governed by the laws and courts of the Province of Alberta. The terms and
conditions of this Agreement are severable to the extent that any one which may be contrary to
the laws of Alberta shall be deemed to be modified to comply with those laws, but every other
term and condition shall remain valid.

15. Time is of the essence in this Agreement.

16. The Legal Owner shall be entitled to rely upon positions taken by and directions received from
the Minister’s representative and shall have no obligation to seek further assurances or
confirmation from the Minister regarding a position taken by or a direction received from the
Minister’s representative. The Director, Program Support and Stakeholder Relations, is the
Minister’s representative.

17. The Minister shall be entitled to rely upon positions taken by and directions received from the
Legal Owner’s representative and shall have no obligation to seek further assurances or
confirmation from the Legal Owner regarding a position taken by or a direction received from the
Legal Owner’s Representative. Name of Institution’s Representative is the Legal Owner’s
representative.

18. A waiver of a breach of a term of this Agreement shall not bind the party giving it unless it is in
writing. A waiver which is binding shall not affect the rights of the party giving it with respect to
any other or future breach.

19. Each party warrants that it has the authority to enter into this Agreement and that this Agreement
does not contravene any law or contract to which it is subject.

20. The Legal Owner shall not assign this Agreement without the prior written consent of the
Minister.

June 2009. Legislative Services Branch -4 -

Page 33
 Innovation and Agreement N um ber
Advanced Education agreement number

21. This Agreement contains the entire agreement of the parties concerning the subject matter of this
agreement and no other understanding or agreement, verbal or otherwise, exist between the
parties.

22. The parties shall not change this Agreement except by written agreement.

23. The parties shall continue the performance of their respective obligations during the resolution of
any dispute or disagreement, including during any period of arbitration, unless and until this
Agreement is terminated or expires in accordance with its terms and conditions.

24. Notwithstanding any other provisions of this Agreement, Sections 11,12 and 13 shall survive this
Agreement and shall continue to bind the parties.

25. This Agreement shall come into effect on the date at the beginning of this Agreement and shall
remain in effect until one of the parties gives the other party 50 (fifty) days’ written notice, or
such additional time as may be required, of its intention to terminate this Agreement.

THIS AGREEMENT HAS BEEN EXECUTED by the parties as of the date at the beginning of this
Agreement.

Owner’s Name, Legal Owner of i>amc ui HER MAJESTY THE QUEEN IN RIGHT OF
Institution ALBERTA as represented by the Minister of
Innovation and Advanced Education

Name Name

Executive Director, Student Aid

Title Title

Legal Owner’s Signature Per: Minister

Witness Witness

June 2009. Legislative Services Branch -5 -

Page 34
 Innovation and Agreement N um ber
Advanced Education agreement number

This is Schedule A to Agreement Number:________ between HER MAJESTY THE QUEEN IN RIGHT OF
ALBERTA as represented by the Minister of Innovation and Advanced Education and Owner’s Name. Legal
Owner of Name of Institution and forms part of this Agreement.

SCHEDULE A

Signatures of the Institution’s Appointed Officials

I,_____Owner’s Name, Legal Owner of Name of Institution confirm that:

1. The Institution staff identified below have authority to confirm registration, sign cheque registers, and/or
sign loan documents for students attending Name of Institution_____. and that these responsibilities will
be carried out in accordance with the requirements of the Learner Funding Program.

2. The signatures appearing immediately below is (are) that of the official(s) appointed by the Legal Owner to
provide counseling to students, supervise and administer the Institution’s role in the Alberta Student Loans
Program, and to sign loan documents issued in accordance with the Canada Student Financial Assistance
Act, and the Alberta Student Financial Assistance Act.

Signature

Name (printed)

Position Title IT e
Signature

Name (printed)

Position Title

Signature

Name (printed)

Position Title

Signature of Legal Owner Date

June 2009. Legislative Services Branch -6 -

Page 35
 Disability Grant for
Disability Grants
PO Box 28000 Stn Main Services and Equipment
Edmonton AB T5J 4R4
Reconciliation Worksheet
Student Aid Alberta

N am e:______________________________________ Social Insurance Number:

DEADLINE: This worksheet and all receipts must be returned by the end of your current study period. If you do
not provide receipts or return your unused funds, you will have a grant overaward that will reduce
your future eligibility for this grant.

INSTRUCTIONS:

1. Collect all your receipts and submit them at the same time, along with this worksheet.
2. Your receipts must indicate that you purchased approved services and/or equipment during the pre-study or
study period.
3. Submit only receipts that verify the amounts as paid or that show the method of payment (example:
Visa). Invoices alone cannot be accepted.
4. Write your name and Social Insurance Number (or Alberta Student Number) on all your receipts.
5. Complete the worksheet as in the example below. Attach your receipts to this worksheet.
6. If you have unused funds of less than $25, you do not need to repay the funds.
7. If you have unused funds of $25 or more, you must repay the funds. Make your cheque or money order
payable to: Government of Alberta.
8. Mail this worksheet, receipts, and cheque or money order (for unused funds, if applicable) to:
Student Aid Alberta
Attention: Disability Grants
PO Box 28000 Station Main
Edmonton AB T5J 4R4

EXAMPLE:

Cost Type $$ Awarded $$ Spent Receipt Attached? $$ To Be Returned

Zoomtext $700 $700 yes 0
Tutor $1200 $1000 yes $200

WORKSHEET:

Cost Type $$ Awarded $$ Spent Receipt Attached? $$ To Be Returned

Total Unused Funds = $

October 2013
Page 36
 ALEXANDER RUTHERFORD
S tudent A id A lberta
High School Achievement Scholarship
Award Value - Up to $2,500
Named in honour of Alexander Rutherford, Alberta’s first Premier and Minister of Education, the Alexander Rutherford Scholarship recognizes
and rewards exceptional academic achievement in high school and encourages students to pursue post-secondary studies.

Eligibility Criteria

A student must meet the required average based on five
designated courses in at least one grade: Grade 10,11 or 12.
The required average, value of the award, and courses that can be
used depend on the year the student graduated from high school.
In 1999, the value of the award was increased; in April 2006, two
Grade 12 options of five credits each are now accepted (see
Course Requirements); in April 2008, a new scholarship was
added for students who attain an average of 75.0% to 79.9%.
Applicants must:
• be a Canadian Citizen, Permanent Resident, or Protected
Person. You are eligible only for the years you were a Citizen,
Permanent Resident, or Protected Person, e.g. if you became
a Permanent Resident in Grade 12, then you are eligible only
for the Grade 12 year of the scholarship.
- Visa students are not eligible.
• be an Alberta resident. This means that the applicant or one of
the applicant’s parents must have resided in Alberta during the
qualifying grades.
• have completed high school on or after September 30,1980.
• have attained an overall required average in five designated
subjects in either Grade 10,11 and/or 12 as calculated
from marks on a valid Alberta Transcript of High School
Achievement* (see Course Requirements). If a student
meets the required overall average for any of the above grades,
the amount of the scholarship will be calculated accordingly.
* If high school grades were completed outside of Alberta,
see NOTES on the next page for required documents.
• be accepted in a full-time post-secondary or apprenticeship
program.
NOTE: Averages are not rounded-up for scholarship
purposes. All courses must be completed before starting
post-secondary studies.

Application Procedure

There is no application deadline for the Alexander Rutherford
Scholarship. Students are encouraged to apply once they are
accepted by their preferred post-secondary institution.
Rutherford Scholars Award recipients, see below, will be
notified after February 1. A separate application is not required.
Transcripts are not required for courses completed in Alberta.
Only marks recorded on a valid Alberta Transcript of High
School Achievement will be accepted. High school grades
obtained through upgrading at a post-secondary institution
are not accepted.
Eligible students who complete high school outside of Alberta
must submit an official transcript of their high school marks
from that province.
Students will be notified by mail of the status of their
application.
Students must notify Student Aid Alberta of any changes
to their application, e.g. change in address or change in
post-secondary institution.
In the event of a mark change, send a revised Alberta
Transcript of High School Achievement or Detailed Academic
Report to Student Aid Alberta.

Rutherford Scholars - Selected on applications received by February 1

The top ten (10) Alberta students, selected from all the Alexander Qualifying subjects are:
Rutherford Scholarship applications received, are recognized
• One of: Plus any three of:
as Rutherford Scholars and receive an additional $2,500. The
English 30-1, 30-2, Mathematics 31
top ten students are determined on the first writing of Diploma
or Frangais 30, 30-2 Mathematics 30-1, or 30-2
Examinations from qualifying subjects.
and Biology 30
Social Studies 30-1 or 30-2 Chemistry 30
Physics 30
Science 30

Questions? Contact Student Aid Alberta

Telephone: 1-855-606-2096 (toll free in North America)

studentaid.alberta.ca

Page 37
 Course Requirements
GRADE 10 (See NOTES)
Average of 75.0% to 79.9% in five subjects - $300
Average of 80.0% or higher in five subjects - $400
• One of: English 10-1, 10-2,
Frangais 10, 13 or 10-2, and
• At least two of the following:
Mathematics 10C
Science 10
Social Studies 10-1 or 10-2
A language other than the one used above
at the Grade 10 level, and
• Any two courses with a minimum three credit value at the
Grade 10 level (1000 or 4000 series) including those listed
above and combined introductory CTS courses.*
GRADE 11 (See NOTES)
Average of 75.0% to 79.9% in five subjects - $500
Average of 80.0% or higher in five subjects - $800
• One of: English 20-1,20-2,
Frangais 20, 23 or 20-2, and
• At least two of the following:
Mathematics 20-1, or 20-2
Science 20
Biology 20
Chemistry 20
Physics 20
Social Studies 20-1 or 20-2
A language other than the one used above
at the Grade 11 level, and
• Any two courses with a minimum three credit value at the
Grade 11 level (2000 or 5000 series) including those listed
above and combined intermediate CTS courses.*
GRADE 12 (See NOTES)
Average of 75.0% to 79.9% in five subjects - $700
Average of 80.0% or higher in five subjects - $1,300
• One of: English 30-1,30-2,
Frangais 30, 30-2, and
• At least two of the following:
Mathematics 31
Mathematics 30-1, or 30-2
Science 30
Biology 30
Chemistry 30
Physics 30
Social Studies 30-1 or 30-2
A language other than the one used above
at the Grade 12 level, and
• Any two courses with a minimum five credit value at the
Grade 12 level (3000, 6000 or 9000 series) including those
listed above and combined advanced CTS courses.*
*CTS Courses
Three one-credit modules can be combined and used
as an option at the Grade 10 and Grade 11 level.
Five one-credit modules can be combined and used
as an option at the Grade 12 level as of April 2006.
To be combined:
• all courses must be from the same level,
e.g. Introductory, Intermediate or Advanced, and
• courses can be from different streams or subject areas,
e.g. computer courses with welding courses, and
• marks will be averaged at the appropriate level.
NOTES
• French and Frangais are not the same course and are
not interchangeable.
• A course cannot be repeated after a higher level course
has been taken in the same series.
• Averages are not rounded up for scholarship purposes.
• The value of the scholarship is calculated on the overall
average in five designated courses as listed under each
grade level.
• All courses listed on an official Alberta Transcript of High
School Achievement are acceptable (excludes Driver’s
Education), and only marks obtained before the start
of post-secondary study can be used.
• Courses with a “Pass” on an Alberta Transcript of High
School Achievement are equivalent to a 50% mark.
• If high school grades were completed outside of Alberta,
a letter indicating where the applicant or their parent(s) lived
during the Grade 10, Grade 11 and Grade 12 school years
and a copy of the transcript for the grade(s) completed
must be submitted.
• Regarding CALM, this course can be taken in any grade,
but the final mark will be calculated in Grade 11.
Additional Information
Visit the website for:
• course requirements prior to April 1,2008
• a list of Frequently Asked Questions
studentaid.alberta.ca
Page 38
 ALEXANDER RUTHERFORD
S tudent A id A lberta
High School Achievement Scholarship
Innovation and Advanced Education is collecting the personal information on this form under the authority of section 33(c) of the Freedom
o f Inform ation an d Protection o f Privacy A c t (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship
under the Alberta Heritage Scholarship A c t and to administer scholarships including research, statistical analysis and program evaluation.
The use and disclosure of your personal information is managed in accordance with the FOIP Act.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, PO Box 28000 Station Main,
Edmonton AB T5J 4R4.

Personal Information

*Names on certificate will be printed exactly as entered below.

Last Name* (current legal name) Social Insurance Number

__L I I I _L I I I _L I I L _ L _ L _ L _ [ _ l__
d id d le
First Name* (current legal name) n itia l

I I I I I I I I I I I I I I I □ Gender □ Male □ Female

Apartment or Box Number

Day Month Year
Birthdate

Street Address

Previous Last Name (if applicable)

City/Town

Date completed/last attended regular High School

Prov/State Country Postal/Zip Code (excludes upgrading)
Month Year

Mobile Number (format: 999-999-9999) to receive text messages

Alberta Student Number (mandatory)

(obtained from Alberta Transcript fo r High School Achievement,
o r call toll free in Alberta at 310-0000 to have a Request for
Alberta S tudent N um ber form m ailed to you)

Did you or one of your parents live in Alberta during your

Citizenship Status: (check one)
entire Grade 10, Grade 11 and Grade 12 school years?
□ Canadian
Yes Q No If no, please include:
□ Permanent Resident
• a letter indicating where you or your
If Permanent Resident, card issue date: parent(s) lived during those three years,
Month Year and
• a copy of your transcript for the grade(s)
completed outside of Alberta
□ Protected Person

Aboriginal Status (voluntary):

□ Status Indian/First Nations Providing personal information on Aboriginal students will help measure the effectiveness
□ Non-Status Indian/First Nations of student financial assistance programs in relation to Aboriginal students and to research
programs and services to improve student success rates. If you wish to declare your
I I Metis Aboriginal heritage, please check the box that applies to you.
l~ ) Inuit

A L E X A N D E R R U T H E R F O R D S C H O L A R S H IP L a s t re v is e d J u n e 2 0 1 5 F o r O ffice Use Only A p p ID

Page 39
 Page 2

Post-Secondary Institution Information - You must be accepted for full-time studies before you can apply.

Educational Institution Name Study Start Date

Month Year
I I I I I I I I I
Address J___ L J___ I__

I I I I I I I I I I I
City/Town Prov/State

I I I I I I I I I I I
Country Postal/Zip Code

I I I I I I I I I I I I I I I I

High School Information

Name of High School (Graduating high school) Have you previously applied for an
Alexander Rutherford Scholarship?
□ Yes □ No If yes, what year?
City/Town Prov/State

I I I I I I I I I I I I I I I
Country

I I I I I I I I I

Declaration of Applicant

I have read and understand the instructions, and declare that: » personal information may be released and exchanged by and
• all information provided is true and complete and I understand between Student Aid Alberta and any provincial government
it is subject to audit. departments, boards or institutions to verify the information
I have provided to Student Aid Alberta, and for the use in
• I will be a full-time student at the institution named for the study
research and statistical analysis in program evaluation.
start date stated.
understand and agree that:
I understand that:
» if I receive a scholarship my name, award, and city/town may
• personal information pertaining to my high school academic
be released publicly to promote the program. My name, the
record may be released and exchanged by and between the
name of the scholarship and the scholarship amount may also
department of Alberta Education and Student Aid Alberta for
be published on the Government of Alberta Grant Disclosure
the purpose of determining my eligibility for the Alexander
Portal. However, my consent to the publication of this personal
Rutherford Scholarship.
information is not a criterion for eligibility, and if I do not want to
• personal information pertaining to my post-secondary be identified, I will contact Student Aid Alberta and request that
academic enrollment status may be released and exchanged it not be disclosed.
by and between Student Aid Alberta and the educational
institution for the purpose of determining my eligibility for
a scholarship.

Signature of Applicant (in ink) Today’s Date (in ink)

Day Month Year
X
_ u ! 1 1 i i i

Please Review Your Application to Make Sure you Have Completed All the Required Fields.
Missing Information Will Delay Processing.

Mailing Address

STUDENT AID ALBERTA

PO BOX 28000 STN MAIN
EDMONTON AB T5J 4R4

Page 40
Alexander Rutherford
High School Achievement
Scholarship

better Page 41
 ALEXANDER RUTHERFORD
High School Achievement Scholarship
Named in honour of Alexander Rutherford, Alberta’s first Premier and Minister of Education. The Alexander Rutherford
Scholarship recognizes and rewards exceptional academic achievement in high school and encourages students to pursue post­
secondary studies.

Award Value - Up to $2,500

Eligibility Criteria
A student must meet the required average based on five designated courses in at least one grade: Grade 10, 11 or 12. The required
average, value of the award, and courses that can be used depend on the year the student graduated from high school. In 1999, the
value of the award was increased; in 2006, two Grade 12 options of five credits each are now accepted; in 2009, a new scholarship
was added for students who attain an average of 75.0% to 79.9%. Please visit the website for further details.
Applicants must:
*bc a Canadian Citizen or permanent resident,
*be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the qualifying grades,
*have completed high school on or after September 30, 1980,
*have attained an overall required average in five designated subjects in either Grade 10, 11 and/or 12 as calculated from
marks on a valid Alberta Education transcript. If a student meets the required overall average for any of the above Grades,
the amount of the scholarship will be calculated accordingly.
*be enrolled full-time in a post-secondary or apprenticeship program.

NOTE: Averages are not rounded-up for scholarship purposes.

All courses must be completed before starting post-secondary studies.

Application Procedure

Apply by May 1 for post-secondary studies starting in September or by December 1 for post-secondary studies starting in January.
Applications must be post-marked by the application deadline.

Students who apply after May 1 may not be recognized at their high school awards ceremony and will not be assessed for a
Rutherford Scholar Scholarship.

Transcripts arc not required for courses completed in Alberta. Only marks recorded on a valid Alberta Education transcript will be
accepted. High school grades obtained through upgrading at a post-secondary institution are not accepted. Eligible students who
complete high school outside of Alberta must submit an official transcript of their high school marks from that province.

Students will be notified by mail of the status of their application in late August for September start date and mid-February for
January start date. The award is issued in November for students who applied by May 1, and in April for students who applied by
December 1.

Students must notify the office of Alberta Scholarship Programs of any changes to their application.

In the event of a mark change send a revised Alberta Education transcript or course mark statement to Alberta Scholarship
Programs.

Faxed or Scanned Applications are not accepted:

Mail to: Courier or Deliver to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor-9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1
Office Hours: Monday to Friday from 8:15 to 4:30
website: www.alis.alberta.ca/scholarships
 2014 Course Requirements

GRADE 11
GRADE 10
Average of 75.0% to 79.9% in five subjects - $500
Average of 75.0% to 79.9% in five subjects - $300 Average of 80.0% or higher in five subjects - $800
Average of 80.0% or higher in five subjects - S400
• One of: English 20-1, 20-2,
• One of: English 10-1, 10-2, Fran?ais 20, 23 or 20-2, and
Franqais 10, 13 or 10-2, and • At least two of the following:
• At least two of the following: Mathematics 20-1, or 20-2
Mathematics 10C Science 20
Science 10 Biology 20
Social Studies 10-1 or 10-2 Chemistry 20
Physics 20
a language other than the one used above at the
Social Studies 20-1, or 20-2
Grade 10 level, and a language other than the one used above
• Any two courses with a minimum three credit value at at the Grade 11 level, and
the Grade 10 level (1000 or 4000 series) including those • Any two courses with a minimum three credit value at
listed above and combined introductory CTS courses. the Grade 11 level (2000 or 5000 scries) including those
See NOTES listed above and combined intermediate CTS courses
See NOTES

X
CTS Courses: Three one credit modules can be combined and used as an option at the Grade 10 and Grade 11 level. Ed
X
Five one credit modules can be combined and used as an option at the Grade 12 level as of April 2006.
To be combined:
• all courses must be from the same level, i.e. Introductory, Intermediate or Advanced,
• courses can be from different streams or subject area, e.g. computer courses with welding courses, and
• marks will be averaged at the appropriate level. X
<
GRADE 12 u
Average of 75.0% to 79.9% in five subjects - $700 NOTES: H
Average of 80.0% or higher in five subjects - $1,300 • French and Franqais are not the same course and are not
interchangeable. Ed
• One of: English 30-1, 30-2 • A course cannot be repeated after a higher level course has
Franqais 30, 30-2, and• been taken in the same series. (Z3
• At least two of the following: • Averages are not rounded up for scholarship purposes.
• The value of the scholarship is calculated on the overall <
Mathematics 31
Mathematics 30-1, or 30-2 average in five designated courses as listed under each Ed
Science 30 grade level.
Biology 30 • All courses showing on a valid Alberta Education high J
Chemistry 30 school transcript arc acceptable, and only marks earned
CL
Physics 30 before the start of post-secondary study can be used.
Social Studies 30-1 or 30-2 • Courses with a “Pass” on a high school transcript are
a language other than the one used above at equivalent to a 50% mark.
the Grade 12 level, and • Regarding CALM, this course can be taken in any grade,
• Any two courses with a minimum five credit value at the but the final mark will be calculated in Grade 11.
Grade 12 level (3000, 6000 or 9000 series) including those
listed above and combined advanced CTS courses. Additional Information:
See NOTES Visit www.alis.alberta.ca/scholarships for a list of Frequently
Asked Questions.

alis.alberta.ca/scholarships
Page 43
 RUTHERFORD SCHOLARS
2014 Course Requirements

A separate application form is not required.

The top ten ( 10) Alberta students, as determined on the first writing of Diploma Examinations, are recognized as “Rutherford
Scholars”and receive an additional $2,500 and a plaque.

Qualifying subjects are:

• One of: English 30-1, 30-2,

or Frangais 30, 30-2, and
• Social Studies 30-1 or 30-2

• Plus any three of:

Mathematics 31
Mathematics 30-1, or 30-2
Biology 30
Chemistry 30
Physics 30
Science 30

Recipients are selected on applications received by May 1.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

The Alexander Rutherford Scholarship is funded through the Alberta Heritage Scholarship Fund. This program was created by a $100
million endowment from the Alberta Heritage Savings Trust Fund and is designed to stimulate the pursuit of excellence by rewarding
outstanding achievement and assisting Albertans to achieve their fullest potential.

Further information about the Alberta Heritage Scholarship Fund and scholarships offered contact:

Alberta Scholarship Programs

Telephone: 780.427.8640 Toll Free (Rite Line): 310.0000 Email: scholarships@gov.ab.ca
Website: www.alis.alberta.ca/scholarships

For information on over 500 awards, bursaries, scholarships sponsored by various companies, organizations, and associations visit the
alis website and click on “Scholarship Connections”.

Institution Codes
For additional institution codes, check the institution code listing at www.alis.alberta.ca/pdf/scholarships/codes.pdf.

University of Alberta....................... 2201
University of Calgary...................... 2202
University of Lethbridge.................. 2203
NAIT................................................ 2221
SAIT................................................ 2222
Alberta College of Art & Design.....5110
Ambrose University College........... 9041
Athabasca University....................... 2204
Banff Centre..................................... 2227
Bow Valley College......................... 2218
Concordia University College (AB)..2246
Devry Institute of Technology.......... 2040
Grande Prairie Regional College...... 2241
Grant MacEwan University.............. 2247
Kcyano College................................ 2230
Kings University College................. 2255
Lakeland College.............................. 2225
Lethbridge College........................... 2220
Medicine Hat College...................... 2242
Mount Royal University.................. 2243
Northern Lakes College................... 2020
Norquest College............................. 2226
Olds College.................................... 2224
Portage College................................ 2219
Red Deer College............................. 2244
St. Mary’s University College......... 5661
Taylor College.................................. 2268

Page 44
 ALEXANDER RUTHERFORD
High School Achievement Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Please review your application to make sure you have completed all the required fields.
Missing information will delay processing.

Personal Information
Alberta Student Number (required for processing) High School Code Social Insurance Number (required for processing)

First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M
J ____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN o ] PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
Did you or your parent(s) live in Alberta during your entire Grade 10, Grade 11 AND Grade 12 school years?
If no, please include a letter indicating where you or your parent(s) lived during those three years.
Providing personal information on Aboriginal students will help measure the effectiveness of student financial assistance
programs in relation to Aboriginal students and to research programs and services to improve student access rates. If you
wish to declare your Aboriginal heritage, please specify:
S ta tu s : First Nations Non-Status Metis Inuit

PROPOSED POST-SECONDARY STUDIES (In d ic a te first choice)

Name of Institution Institution Code (Note: See list for institution codes.)

I I I I I
Location (If outside Alberta, please give com plete address.) Start Date (Month/Year
Office Use Only

Revised January 2014

Page 45
 Personal Information (continued)

SECONDARY EDUCATION
Name of High School

1 HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. 1 will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full­
time studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT:
a. personal information pertaining to my high school academic record may be released and exchanged by
and between the department of Alberta Education and Alberta Scholarship Programs for the purpose of
determining my eligibility for the Alexander Rutherford Scholarship;
b. personal information pertaining to my post-secondary academic enrollment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. personal information may be released and exchanged by and between Alberta Scholarship Programs
and any provincial government departments, boards or institutions to verify the information 1 have
provided to Alberta Scholarship Programs and for the use in research and statistical analysis in program
evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, 1 will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Check List:
I I Alberta Student Number - required for accessing your Alberta high school transcript. Students who have attended high
__ school outside Alberta must submit an official transcript from that province.
— High School Code - essential in identifying where you completed high school.
I I Social Insurance Number - application cannot be processed without it.
I | Permanent Resident - attach a photocopy of either permanent resident card or landed immigration long form,
n Alberta Residency - If you or your parent(s) have not lived in Alberta during your entire Grade 10, 11 and 12,
include a letter indicating where you or your parent(s) lived for those three years,
n Post-Secondary Studies - indicate the name of your first choice of post-secondary institution and code in order that our
office may confirm your full-time enrollment. If you decide to attend another institution, please notify our office.
I— I Signature - sign and date the application

Faxed or Scanned Applications are not accepted:

Mail to: Courier or Deliver to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1
Page 46
 Anna & John
Kolesar
Memorial Scholarship

_ /Q ib e f b c ^ M
Page 47
 ANNA & JOHN KOLESAR MEMORIAL SCHOLARSHIP
This scholarship honours the memory of Anna and John Kolesar, the parents of Dr. Henry Kolesar, Deputy Minister of Alberta
Advanced Education from 1976 to 1987. Longtime residents of the Millet area, the Kolesars were lifelong advocates of the
importance of higher education, providing encouragement and support to all who chose academic pursuits. Originally from
Hungary, Anna and John Kolesar arrived in Alberta in 1927, contributing much to their community and province in the many years
they lived in Millet. Upon his retirement in 1987, Dr. Kolesar initiated the scholarship with a generous endowment that was
supported by contributions from friends and colleagues.

Award Value - $1,500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Permanent Resident,
b. be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the
qualifying grades,
c. be from a family where neither parent obtained a university degree, and
c. intend to pursue a program of study in a Faculty of Education.

Selection Procedure
The recipient will be selected on the basis of academic excellence as calculated from the final standings received in three subjects as
recorded on an Alberta Education transcript. The subjects shall include:
One of: English30, English 30-1, 30-2 or Francais 30, 30-2 and

Any two of the following: Pure Mathematics 30 Applied Mathematics 30 Mathematics 3 1

Mathematics 31 Science 30 Mathematics 30-1, or 30-2
Biology 30 Chemistry 30 Physics 30
Social Studies 30, 30-1 or 30-2 or a language other than the one used above at the Grade 12 level
In the event of a tie the applicant with the highest average of the Diploma Examination marks for the qualifying courses will be the
recipient.

Application Procedure

Applicants will be notified of the status of their application in September. The award will be issued in November after Alberta
Scholarship Programs confirms the recipient’s full-time enrolment in a Faculty of Education.

FAXED OR SCANNED A PPL ICA TIONS A RE SO T ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.gov.ab.ca/scholarships

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Application Deadline: Julyl

Page 48
 ANNA & JOHN KOLESAR MEMORIAL SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M day month year
___L__ ___I___ ___L__I___ I___
Have either of your parents obtained a university degree? Y N

CITIZENSHIP (check one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N Y N

Have you lived in Alberta all your life?

IF YOU ANSWERED ‘NO’ TO EITHER OF THESE QUESTIONS
Y N Since month year PLEASE INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
___I______ I______ I___

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code (Note: See back page for institution codes.)

Institution City Entry Date for Program Program

month . year .

POST-SECONDARY STUDENT I.D. NUMBER

Office Use Only

Revised: March 2013

Page 49
 Personal Information (continued)

SECONDARY EDUCATION
Name of High School

Town/City Province

Date of Completion of High School Have you previously applied for an Alexander Rutherford Scholarship?
Y N I f ‘YES’ what year?
___1___ 1
___l___ 1___ 1___
year

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between Alberta
Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
If your institution code is not listed here, check the institution code listing at .alis.gov.ab.ca/ndf/scholarships/codes.pdf.

University of Alberta....................... 2201
University of Calgary...................... 2202
University of Lethbridge................. 2203
NAIT................................................ 2221
SAIT................................................ 2222
Alberta College of Art & Design.....5110
Ambrose University........................ 9041
Athabasca University....................... 2204
Bow Valley College......................... 2218
Concordia University College (AB)..2246
Devry Institute of Technology.......... 2040
Grande Prairie Regional College...... 2241
Grant MacEwan University.............. 2247
Keyano College................................ 2230
Kings University College................. 2255
Lakeland College.............................. 2225
Lethbridge College........................... 2220
Medicine Hat College....................... 2242
Mount Royal University 2243
Northern Lakes Collegee..................2020
Norquest College............................. 2226
Olds College.................................... 2224
Portage College................................ 2219
Red Deer College............................. 2244
St. Mary’s......................................... 5661
Taylor University............................. 2268

Page 50
 Post-Secondary COC Summary Sheet
Student’s Name: (please print) Social Insurance Number: Additional Funds Requested:

Dependents II Monthly Resources (cont’d) II Schedule 1(Singles)

# of Dependent Children Alimony/Child Support Parents Deceased
4 Month Pre-Study Period El Benefits Transportation to Inst.
# Months F/T prior to studies AISH # in Family
Total Earning WCB # in Post Secondary
Summer SFI Indian Affairs Parent 1 Total Income (line 1 50)
Living at (P/O) Other Income Parent 2 Total Income (line 150)
Training Dates Post-Secondary Educational Costs Parent 1 Reduced Income
From (d/m/y) Tuition Parent 2 Reduced Income
To (d/m/y) Fees Parents Share
Maintenance Start Date (d/m/y) Books/Supplies/lnstr. Schedule II (Married)
Maintenance End Date (d/m/y) Computer Costs Spouse (line 150)
Monthly Expenses Other Resources Spouse/Partner Employment
Living with (P/O) Actual Savings Spouse/Partner Gross Income
Rent/Mortgage Assets Spouse/Partner NET Income
Utilities RRSPs Income Start Date (m/y)
Food/Clothing/Personal Care Other Resources Income End Date (m/y)
Transportation Spouse/Partner Attending? (Y/N)
Med Not Insured Spouse/Partner Start Date (d/m/y)
Child Care/Babysitting Scholarship Amount(s) Spouse/Partner End Date (d/m/y)
Child Support Data Entry Req’d
Monthly Resources Overpayment Internet Y N
Wages/Salary (net income) Special Instructions Copy#
Spouse/Partner (net income)
RJ NIL
Backdate required:
Assistantships
S SP M
Bursaries/Stipend
Contribution from parents

Notes to File/Rationale:

Signature: Authorization #: Date:

Day Month Year
_____ I______L 1
Reject Letter (RJ): (letter options) App ID:

□ 1 _J__I__L J_J__I__L
SN MSG: (rev June 2014)

Page 51
 Post-Secondary Special Circumstances and Expenses
Student’s Name: (please print) Social Insurance Number: Additional Funds Requested:

W q Student’s request for special expenses has been reviewed and denied.

Special Expenses Amount dumber of Months Total Special Circumstances V'es (indicate Y)
hlo (indicate N)
Alimony/Child Support Monthly X
Allow Additional Prov. Loan
Actual Childcare Monthly X
Allow Away-from Flome Budget*
Dental Monthly X
Allow Second Residence
Additional Medical Monthly X
Tuition & Books Award only*
Additional Mortgage Monthly X
Allow GFD
Optical Monthly X
Allow Maintenance Grant
Other Expenses Monthly X
Allow Provincial Residency Status*
Additional Rent Monthly X
Allow Special Independent Status*
Spouse/Partner Student Loan
X
Payments Monthly Waive Assets*
Additional Travel Monthly X Waive Parental Contribution*
Additional Utilities Monthly X Waive Student Contribution*
Dental Yearly ---------- ► Waive Spouse/Partner Contribution*
Medical Yearly ---------- >■ Allow LIFG
Optical Yearly (Max. $300/yr) ---------- ► Allow MIFG
Other Expenses Yearly X Allow SGDC
This figure cannot exceed Allow SPDG
Exceptional Parent Expenses Yearly $10,000 and is not to be included
in the column marked “Total”. Allow FSEG
| Allow payment of special $ Total for Allow ALIG
expenses in one disbursement. this Award

Notes to File/Rationale:

Signature: Authorization #: Date:

Day Month Year
I I I , I , I i i i
Signature of Authorized Supervisor/Manager: Authorization #: Date:
(if required) Day Month Year

I I I > 1 , 1 i i i
Reject Letter (RJ): (letter options) AppID:

□ i i i i 1 1 1 1 i i i
SN MSG: (rev June 2014)

Page 52
 Post-Secondary COC Summary Sheet
Student’s Name: (please print) Social Insurance Number: Additional Funds Requested:

Dependents II Monthly Resources (cont’d) II Schedule I (Singles)

# of Dependent Children Alimony/Child Support Parents Deceased
4 Month Pre-Study Period El Benefits Transportation to Inst.
# Months F/T prior to studies AISH # in Family
Total Earning WCB # in Post Secondary
Summer SFI Indian Affairs Parent 1 Total Income (line 1 50)
Living at (P/O) Other Income Parent 2 Total Income (line 150)
Training Dates Post-Secondary Educational Costs Parent 1 Reduced Income
From (d/m/y) Tuition Parent 2 Reduced Income
To (d/m/y) Fees Parents Share
Maintenance Start Date (d/m/y) Books/Supplies/lnstr. Schedule II (Married)
Maintenance End Date (d/m/y) Computer Costs Spouse (line 150)
Monthly Expenses Other Resources Spouse/Partner Employment
Living with (P/O) Actual Savings Spouse/Partner Gross Income
Rent/Mortgage Assets Spouse/Partner NET Income
Utilities RRSPs Income Start Date (m/y)
Food/Clothing/Personal Care Other Resources Income End Date (m/y)
Transportation Spouse/Partner Attending? (Y/N)
Med Not Insured Spouse/Partner Start Date (d/m/y)
Child Care/Babysitting Scholarship Amount(s) Spouse/Partner End Date (d/m/y)
Child Support Data Entry Req’d
Monthly Resources Overpayment Internet Y N
Wages/Salary (net income) Special Instructions Copy#
Spouse/Partner (net income)
RJ NIL
Backdate required:
Assistantships
S SP M
Bursaries/Stipend
Contribution from parents

Notes to File/Rationale:

Signature: Authorization #: Date:

Day Month Year

_____ I______L 1
Reject Letter (RJ): (letter options) App ID:

□ 1 _J__I__L J_J__I__L
SN MSG: (rev June 2014)

Page 53
 Post-Secondary Special Circumstances and Expenses
Student’s Name: (please print) Social Insurance Number: Additional Funds Requested:

W q Student’s request for special expenses has been reviewed and denied.

Special Expenses Amount dumber of Months Total Special Circumstances V'es (indicate Y)
hlo (indicate N)
Alimony/Child Support Monthly X
Allow Additional Prov. Loan
Actual Childcare Monthly X
Allow Away-from Flome Budget*
Dental Monthly X
Allow Second Residence
Additional Medical Monthly X
Tuition & Books Award only*
Additional Mortgage Monthly X
Allow GFD
Optical Monthly X
Allow Maintenance Grant
Other Expenses Monthly X
Allow Provincial Residency Status*
Additional Rent Monthly X
Allow Special Independent Status*
Spouse/Partner Student Loan
X
Payments Monthly Waive Assets*
Additional Travel Monthly X Waive Parental Contribution*
Additional Utilities Monthly X Waive Student Contribution*
Dental Yearly ---------- ► Waive Spouse/Partner Contribution*
Medical Yearly ---------- >■ Allow LIFG
Optical Yearly (Max. $300/yr) ---------- ► Allow MIFG
Other Expenses Yearly X Allow SGDC
This figure cannot exceed Allow SPDG
Exceptional Parent Expenses Yearly $10,000 and is not to be included
in the column marked “Total”. Allow FSEG
| Allow payment of special $ Total for Allow ALIG
expenses in one disbursement. this Award

Notes to File/Rationale:

Signature: Authorization #: Date:

Day Month Year
I I I , I , I i i i
Signature of Authorized Supervisor/Manager: Authorization #: Date:
(if required) Day Month Year

I I I > 1 , 1 i i i
Reject Letter (RJ): (letter options) AppID:

□ i i i i 1 1 1 1 i i i
SN MSG: (rev June 2014)

Page 54
/dlbcrta
A dvan ced E duca tion
and Technology

PROGRAM COMPLIANCE & INVESTIGATIONS

AUDIT RESULTS

Social Insurance > umber

STUDENT’S NAME:

OBJECTIVE: To ensure that clients meet eligibility requirements for financial assistance and that awards are administered
in compliance with departmental policies and procedures and the Students Finance Act and Regulations.

PERIOD(S) AUDITED:

ACADEMIC PERIOD APPLICATION KEY CLEAR

FORM S NOVEM BER 2009

P a n p fi.
Arts Graduate
Scholarship

A ii& r t lk ji
 ARTS GRADUATE SCHOLARSHIP
Funded by Alberta Heritage Scholarship Fund, the Arts Graduate Scholarship recognizes and encourages Alberta students who have
demonstrated outstanding ability in the arts pursue graduate study.

Award Value - $15,000

Eligibility Criteria

Up to seven awards are available for master level or equivalent level of study in music, drama, dance, literary arts, and the visual arts.

Applicants must:

• be a Canadian citizen or a Permanent Resident,

• be an Alberta resident, and
• enrolled or planning to enroll full-time in a graduate program at the master level or its equivalent.

Previous recipients are eligible to re-apply. An individual may receive a maximum of two awards.
Recipients may hold other awards and accept remunerative assignments depending on the policy of the institution they attend.

Application Procedure
An application form can be obtained in pdf from our website, however, you cannot send your application electronically. Complete the
application form and mail the original and attachments, unstapled.

Academic transcripts and references can be sent directly to Alberta Scholarship Programs. Applicants must ensure their application
is complete. To verify the completeness of your application, send an email to our office: scholarships@gov.ab.ca with your full
name and social insurance number.

FAXED APPLICATIONS ARE NOT ACCEPTED

to: Courier to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940-106 Street
EDMONTON AB T5J 4R4 EDMONTON AB T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Selection Criteria
Applications are evaluated by a committee appointed by the Presidents of the universities in Alberta. Applications are judged on
previous academic accomplishments, program of study, references, answers to the essay question, and general impressions from the
application form.

Application Deadline: February 1

Deadline for submitting academic transcripts and references: February 15
 ARTS GRADUATE SCHOLARSHIP

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
infonnation, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Y ou m a y u s e th e L e a r n e r R e g is t r y a t w w w .e d u c a t io n .g o v .a b .c a t o f in d y o u r A lb e r t a S t u d e n t N u m b e r o r t o h a v e o n e a s s ig n e d

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (curent full legal nam e) Please use upper and lower case. First Name and One Initial (current full le t al nam e)

Mailing Address (Include Apt. or Box Number) City/Town

Province Postal Code Area Code Telephone Number

Date of Birth Gender Email Address

M F
___ l___ ___ i___ ___i___ i___ i___
day month year

CITIZENSHIP (check one)

□ CANADIAN CITIZEN or [] PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
Have you lived in Alberta all your life? Is Alberta the last place you spent 12 consecutive months
Y N If no, since outside of school? Y N
____ l____ ____ l____ l____ l____
month year

Do either of your parents live in Alberta? Y N

POST-SECONDARY EDUCATION
Highest degree completed:

Current institution: Name of program:

OR Last institution attended: Name of program:

Revised: May 2013

Page 58
 Education Information

Name of institution you will attend this fall:

Level of study: (check one)

H Master Level ] Other

Name of Thesis or Project title:

Please submit a resume and include the following: all Universities, Colleges or Technical Institutes attended to date, including
current institution; list scholarships, awards, and other forms of achievement received; indicate any publications, if any, such as
the name of the journal they were published in, and also include performances/exhibitions (dates, location, etc.).

Essay Question

Title of your proposed program of study

In two pages or less, please provide a detailed description of your proposed program of study, why you are
pursuing your research (if applicable) or creative activity, and what you plan to accomplish during and after
your studies.

Please attach these two pages to your application. Pages must be single-spaced, and enough space between the lines for
legibility, approximately six lines per vertical inch. Font size should not be less than 10 and condensed type is not
acceptable.

Academic Transcripts
List the institutions you are requesting transcripts from (include your surname if it is different on the transcript). If you applied last year
and wish to use the same transcripts, please indicate the specific transcript(s) below:

Page 59
 References

Name the two individuals who will be submitting a letter of reference. Since there are numerous applicants competing for;
limited number of awards, it is important that your referee provide as much detailed information on your program of study,
research (if applicable), and accomplishments.

1) Name: ___________________________________________________________

Position Held: ----------------------------------------------------------------------------------

Institution: ________________________________________________________

2) Name: ____________________________________________________________

Position Held: _______________________________________________________

Institution: ________________________________________________________

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTION, AND DECLARE THAT
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw
from full-time studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT
a. my personal information pertaining to my post-secondary academic record may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may be
released and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs
and any provincial government departments, boards or institutions to verify the information I have
provided to Alberta Scholarship Programs and for the use in research and statistical analysis in program
evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the program.
however, this is not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta
Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

 Complete package must be postmarked no later than February 1.
Official transcripts and appraisals must be postmarked no later than February 15.
Notification of results may be expected in April.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta
Heritage Scholarship Fund is designed to stimulate the pursuit o f excellence by recognizing
outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Alberta Scholarship Programs administers another graduate scholarship, the Sir James Lougheed Award
of Distinction for study outside Alberta. Information on this scholarship is available on our website.

For information on other awards administered by Alberta Scholarship Programs

visit our website:
alis.alberta.ca/scholarships
 ATTENDANCE SHEET: Student Aid Alberta Training

Course Name:
Course Facilitator(s):
Date:
Location;

Participant Name Organization Telephone/E-mail Address

Please P rin t
If fro m an E ducational
In s titu tio n , sp e cify campus

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.
Continue on back, if necessary

Page 62
Participant Name Organization Telephone/E-mail Address
Please P rin t
If fro m an E ducational
In s titu tio n , sp e cify campus

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

Page 63
Government of Alberta ■
Student A id Alberta

CONSENT TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY

Your w ritten consent enables Enterprise and Advanced Education/Human Services to disclose your personal inform ation to
a designated individual in accordance w ith section 40(1) (d) of the Freedom o f Inform ation and Protection o f Privacy Act
(FOIP). If you have any questions regarding the disclosure of inform ation contact the Program Compliance and
Investigation Unit: (Toll free w ithin Alberta: 310-0000) (780) 427 5560, or toll free in Canada at 1-800-222-6485.

I, (Full Legal Name)_________________________________________________________

Social Insurance Num ber__________________________________ authorize Enterprise and Advanced Education

and Human Services to disclose the following personal information to:

Full legal name of person to whom personal information will be disclosed (i.e. Name of family member, lawyer
or other person you authorize to receive the information).

Identifying Information (in order to ensure an accurate match and disclosure)

Relationship to student:____________________________________

Daytime Phone Num ber:____________________________Specify a Password:________________________

□ To disclose all personal information in accordance with FOIP; or

□ Do not disclose this personal information - specify information to be excluded (attach an additional
sheet if necessary):

□ Medical Information including disability information - specify information to be excluded

□ Other personal information - specify information to be excluded

Please indicate the period for which information can be disclosed to the Authorized Person (up to five years from
the date on this Consent Form):

End Date of consent to disclose

(month, day. year)

Signature of Student Signature of Authorized Person

Date Date

FAX SIGNED COPIES WILL BE ACCEPTED

Form: January 2013

■P.a a a-.fi,
 C om m ercial Aviation Training Form
\v < s i \s v \J p o Box 28000 Stn Main
S tudent A id A lberta Edmonton, AB T5J 4R4 15/16
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the Freedom of Information
and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify the Student’s eligibility for financial assistance for Fixed Wing or
Flelicopter Training at a private flight training school in accordance with the Student Financial Assistance Act (Alberta), the Canada Student
Loans Act and the Canada Student Financial Assistance Act, each as may be amended from time to time. The use and disclosure of the
personal information is managed in accordance with FOIP. If you have any questions about the collection, use or disclosure of this information,
call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to
Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.
Your school must complete the Commercial Aviation Training Form if you are pursuing Fixed Wing or Flelicopter Training at a private flight
training school. You must attach the form to your Application for Financial Assistance for Full-Time Post-Secondary Studies. If this is the
first Commercial Aviation Training Form you are submitting, you must also attach a copy of your private pilot license.
The maximum assistance provided by Student Aid Alberta for students to complete an entire fixed wing training program (four components)
or an entire helicopter training program is equivalent to the maximum amount of funding available for four semesters of post-secondary study.
Student Aid Alberta does not fund private pilot license training or the completion of build-up time.

The Authorized Official at the school must complete this form.

Name of School Area Code Telephone

_l— I— I— l— I— I— L
This is to certify that (Name of Student) Alberta Student Number

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Flas applied to enroll for the period From To
Day Month Year Day Month Year

J___ L J___ I___ L _J___ I___ I___ I___ I___ I___ I___ L
Name of Program

The Student will be enrolled in the following flight component(s). One component should not exceed 4 months.
Please check box(es) that apply.
Commercial Airplane Pilot Commercial Helicopter Pilot
□ Commercial Pilot License □ Entire Training Program
□ Multi-Engine Rating □ Partial Training
□ Multi-Engine Instrument Rating
□ Flight Instructor Rating

Curriculum Costs
Tuition Books and Supplies

$ $

I declare that the above named Student is/will be enrolled in the above program and should be able to complete this program within
the time indicated above.
Signature of School Official Title of School Official Date Signed

Printed Name of School Official Phone Number of School Official

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4
Jund^tg® 65
 Student Aid Alberta

Alberta Award for the Study of

Canadian Human Rights &
Multiculturalism
 Alberta Award for the Study of Canadian Human Rights and Multiculturalism

In recognition of Alberta’s centennial and the contributions and experiences of our diverse population, the Minister of Alberta
Community Development established the Alberta Award for the Study of Canadian Human Rights and Multiculturalism. This award
is funded through an endowment by the Human Rights Education and Multiculturalism Fund and is administered jointly by Alberta
Justice and Solicitor General and Alberta Advanced Education.

This award supports graduate studies that explore and support human rights or multicultural questions in Canada. Graduate students
attending an Alberta public post-secondary institution whose studies will contribute to the advancement of human rights and
multiculturalism are encouraged to apply.

Two awards are available each year: Master’s level award is $10,000 and Doctoral level award is $15,000. The Master’s level award
honours one of Alberta’s human rights champions and is known as the Pardeep Singh Gundara Memorial Scholarship.

Purpose
To encourage graduate studies that will create value for Albertans by promoting informed thinking about Canadian human rights,
cultural diversity, and multiculturalism. To support the pursuit of studies in Canadian human rights, cultural diversity, and
multiculturalism, and building capacity to undertake human rights or multicultural work in Canada.

Eligibility Criteria

Applicant must be:

• a Canadian citizen or a Permanent Resident,
• enrolled or plan to enroll as a full-time graduate student (Master’s or Doctoral level) at an Alberta public post-secondary
institution,
• enrolled or plan to enroll in a program of study that supports the purpose of the scholarship, and
• planning to do research that is within a Canadian context and will ultimately benefit Albertans.
Note: The scholarship is not open to students pursuing post-graduate studies.

Selection Procedures
The selection committee will consider each applicant’s information as provided on the application form, the essay, and curriculum
vitae. The essay, however, is the most important component of the application and has the greatest impact on the committee’s
decision.

All applicants will be notified of the result of the competition in May.

Successful applicants may expect to receive their award in October, after Student Aid Alberta confirms their enrollment in graduate
studies.
Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Sendee Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Application Deadline: February 1

Page 67
 Alberta Award for the Study of Canadian Human Rights
and Multiculturalism
Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the Alberta
Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Inform ation

You may use the Learner Registry at e d u c a tio n .g o v .a b .ca to find your Alberta Student Number or to have one assigned

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current foil legal name)

Mailing Address (Include Apt, or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email

M mynth
____ i yT i____

□ CANADIAN CITIZEN or □ PERMANENT RESIDENT (Landed Immigrant)

Note: Include a photocopy of your permanent resident card. Visa students are not eligible.

Education Information:
Name of post-secondary institution in Alberta you will be attending this fall: ----------------------------------------
Name of program --------------------------------------------------------------------------------------------------------------
Date you will be completing the program month/year):--------------------------------------------------------------------

What degree will you obtain? -------------------------------------------------------------------------------------------------

What is your major? ------------------------------------------------------------------------------------------------------------
What is your thesis or project title?--------------------------------------------------------------------------------------------

Olffice Use Only

78 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
Disbursement E
MO YR AUTHORIZATION AWARD KEY APP KEY
Revised: Jan 2016
Page 68
 Essay
The essay is the most important component of the application. Please address the following points in your essay:

1. What are the questions (up to three) you want to explore in your study? Why are they important to you?
2. How will your studies create value for Albertans in the areas of human rights, diversity or multiculturalism?
3. How do you plan to integrate the academic and professional literature about the topic of your study with your own
experiences and perspectives?
4. If your study involves human subjects, how many will be tested/interviewed, etc.
5. What is the likely impact of your research project in Alberta?
6. How do you propose to study the issues and what methodology will you be using to study these issues?

The essay should be no more than 1,200 words, double spaced, no more than six lines per inch, with a minimum font
size of 10. Condensed type is not acceptable.

Application & Selection Procedure

Include with the original application, your essay and curriculum vitae.

The essay is the most important component of the application and has the greatest impact on the committee’s decision.
Please feel free to consult your academic advisor.

Mail the complete package to Student Aid Alberta no later than February 1.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to verification,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing one
semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my post-secondary academic progress and enrollment status may be released and
exchanged by and between Student Aid Alberta and the education institution.
b. personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta
and for the use in research and statistical analysis in program promotion.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program,
however, this is not a criterion for eligibility. If I do not want to be identified, I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on: studentaid.alberta.ca/scholarships

Page 69
 Student Aid Alberta

China-Alberta Award for

Excellence in Chinese

Page 70
 China-Alberta Award for Excellence in Chinese
This scholarship is a collaborative scholarship program supported by the Education Office in the Consulate-General of The People’s
Republic of China in Vancouver and Alberta Education. The award was created in 2013 from contributions by the Education Office in
the Consulate General of the The People’s Republic of China in Vancouver and the Government of Alberta to facilitate Chinese
language and culture promotion in Alberta.

Award Value - $500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parents or a parent must
reside in Alberta,
b. have taken high school Chinese Language and Culture Program 10, 20 and currently be enrolled or have completed level 30,
c. have obtained an average of 80% in all courses, and a minimum average of 90% in Chinese Language and Culture 10, and
20, and
d. be currently enrolled in Grade 12.

Selection Procedure
The applicant will be selected by a committee designated by Alberta Education who will review each student’s marks, a two
paragraph essay and a teacher and/or school recommendation.

Application Procedure*•
Submit to Alberta Scholarship Programs:
• completed application form,
• two paragraph essay on “how will what you learned in the Chinese language and culture program apply to your future
studies and/or career”,
• a letter of recommendation, and
• a copy of your high school transcript.

Students will be notified of the status of their application in June.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K.2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to
achieve their fullest potential.

Application Deadline: April 30

Page 71
 China-Alberta Award for Excellence in Chinese
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and low er case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) Cit\'/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M |day | njontli | ^ ypr |

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.

ALBERTA RESIDENCY
Did you or your parent(s) live in Alberta during your entire Grade 10, 11 and Grade 12 school years?
N If no, please include a letter indicating where you or your parent(s) lived during those three years.

I am currently enrolled or have completed Chinese Language and Culture 30

I have obtained an 80% average in all courses and a minimum of 90% in Chinese Language and Culture 10 and 20
_

I am currently enrolled in Grade 12

Page 72
 Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if 1 do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 73
 Student Aid Alberta

Sir James Lougheed

Award of Distinction

Page 74
 Sir James Lougheed Award of Distinction
The Sir James Lougheed Award of Distinction honours the Calgary lawyer, parliamentarian, senator and cabinet minister who
served in several federal parliaments in the late 1800s and early 1900s.

This award recognizes academic excellence and provides Alberta students in graduate programs with the opportunity for study outside
of Alberta at institutions anywhere in the world. Each year up to fifteen students may be eligible for awards.

Award Value
Master Level $15,000 Doctoral Level $20,000

Eligibility Criteria
Applicants must be:
• a Canadian citizen or a Permanent Resident,
• an Alberta resident, and
• enrolled or planning to enroll as a full-time student in a graduate program at an institution outside Alberta.

Recipients are eligible to re-apply, however, there is a lifetime limit of two scholarships. Recipients will be advised of their
eligibility to hold other awards or to accept partial teaching assignments, or other remunerative assignments. In order to qualify for
a doctoral level scholarship, a student must have completed at least one full year of graduate study or a masters degree.

Application Procedure
The application form is available on the Student Aid Alberta website. Applicants must mail in application forms with any applicable
attachments, unstapled. Transcripts and references must accompany your application. Students must mail their applications to:

Mail to:
Student Aid Alberta
PO Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Incomplete applications will not be submitted to the committee. Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

For information on this award and other scholarships:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Selection Criteria
Applications are evaluated by a committee appointed by the Presidents of the universities in Alberta. Applications are judged on
previous academic accomplishments, program of study, appraiser evaluations, answers to the essay question, and general
impressions from the application form.

Application Deadline:

February 15 postmark for Study in the following September.

Transcripts and references must accompany your application.

Page 75
 Sir James Lougheed Award of Distinction

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
You may use the Learner Registry' at w w w .c d u c a t io n .g o v .a b .c a to find your Alberta Student N um ber or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (curent full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) City/Town

Province Postal Code Area Code Telephone Number

Date of Birth Gender Email Address

M F
____ l____ ____ i____ ____ i____ i____ i____
day month year

CITIZENSHIP (check one)

1 CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)
------------ ------------ Note: Include a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
Y n tn • l.t.-ln,!,-. o nhAfAOAmj Af o o rm io o n t rAci/lAnt aoM Ar im m ioratiA n IAHf

ALBERTA RESIDENCY
Have you lived in Alberta all your life? Is Alberta the last place you spent 12 consecutive months
Y N If no, since outside of school? Y N
____ I____ ____ I____ I____ I____
year
Do either of your parents live in Alberta?

POST-SECONDARY EDUCATION
Highest degree completed:

Current institution: Name of program:

OR Last institution attended: Name of program:

Revised: Jan. 2016

Page 76
 Education Information
(Note: This award is for graduate study outside of Alberta only)

Name of institution you wiU attend this fall?

Level of study (check one):

^M asters | | Ph.D.

What is your Thesis or Project title?_______

Please submit a resume and include the following: all universities, colleges or technical institutes attended to date, including
current institution; list scholarships, awards and other forms of achievement received; indicate any publications, if any, such as
the name of the journal they were published in, also include, if applicable, any presentations/performances/exhibitions (dates,
locations, etc.).

Essay Question

Title of your proposed program of study:

In two pages or less, please provide a detailed description of your proposed program of study, why you are pursuing your
research (if applicable) or creative activity, and what you plan to accomplish during and after your studies.

Please attach these pages (unstapled) to your application. Pages must be single-spaced, and have enough space between the
lines for legibility, approximately six lines per vertical inch. Font size should not be less than 10 and condensed type is not
acceptable.

Page 77
 References

Name the two individuals submitting a reference letter:

As numerous candidates compete for a limited number of awards, ensure references provide detailed information on the
applicant’s program of study, accomplishments and area of research.

Name Position Held

Name Position Held

Institution

Below, list the institutions providing transcripts (include your surname if it is different on the transcript).
If you applied last year and wish to use the same transcript, please indicate the specific transcript(s).

Complete application package must be postmarked no later than February 15.

Transcripts and references must accompany your application.

Notification of results can be expected in April.

Page 78
 Declaration of Applicant
I have read and understand the instruction, and declare that
a. all information provided is true and complete and I understand it is subject to verification;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time
studies before completing one semester of studies.
I understand and agree that
a. my personal information pertaining to my post-secondary academic record may be
released and exchanged by and between Student Aid Alberta and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may
be released and exchanged by and between Student Aid Alberta and the educational
institution for the purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Student Aid Alberta
and any provincial government departments, boards or institutions to verify the information
1have provided to Student Aid Alberta and for the use in research and statistical analysis in
program evaluation.
I understand and agree that
if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want to
be identified, I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund
is designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting
Albertans to achieve their fullest potential.

Student Aid Alberta administers another graduate scholarship, the Arts Graduate Award for Master level study in the field of the Arts.
Information on this scholarship is available on our website.

Information on this award and other scholarships is available on:

studentaid.alberta.ca/scholarships

Page 79
 Student Aid Alberta

Dr. Martha Kostuch

Consensus Building
Legacy Award
 Dr. Martha Kostuch Consensus Building Legacy Award
Dr. Martha Kostuch was a recognized advocate on environmental issues, who built her reputation by bringing various stakeholders
together to find collaborative solutions to the environmental issues facing Alberta.

This award is designed to assist individuals in non-government organizations who wish to expand and enhance their education,
training, knowledge and use of consensus-based decision-making processes.

Up to $15,000 is available annually. Recipients will be reimbursed for direct cost of educational expenses.

Eligibility Criteria

Applicants must:
• be a Canadian Citizen or permanent resident of Canada, and a resident of Alberta, and
• be enrolled or planning to enroll in a course through Alberta Arbitration and Mediation Society Consensus-Building
Certificate Program.
Awards are not retroactive; you cannot apply for a course that has been completed prior to the application deadline.
Awards are not intended to duplicate other funding.

Selection Procedure

A selection committee comprised of one member from Alberta Environment, one member from Alberta Advanced Education, and
one public member, will choose recipients and the value of their awards.

Preference will be given to applicants who:

• are members of an environmental not-for-profit organization,

• are active participants in environmental/resource management consensus-based initiatives,
• have demonstrated openness to multi-stakeholder dialogue, and
• have been an Alberta resident for a minimum of one year.
Note: Applications from other not-for-profit non-governmental organizations will be considered.

Application Procedure

Submit with the application:

• a one-page summary (maximum 1000 words) outlining your interests and activities and how you will use
your consensus-building training,
• a letter of endorsement by a non-government organization, and
• a curriculum vitae/resume highlighting your involvement with environmental not-for-profit organizations.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, AB T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Application Deadline: November 30

Page 81
 Dr. Martha Kostuch Consensus Building Legacy Award

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility
for an award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions
about the collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information

Surname Social Insurance Number

Given Name and Middle Initial

Mailing Address (include Apt. or Box Number) City/Town

CITIZENSHIP (check one) ALBERTA RESIDENCY

CANADIAN CITIZEN OR N Have you lived in Alberta all your life? (circle one)
PERMANENT RESIDENT (Landed Immigrant) If no, since
------ Note: Include a photocopy of permanent resident card or immigration long form.
Visa students are not eligible. month year

Gender (circle one) Birthdate (Day, Month, Year) Email Address

M F
i I i ___I___ I___ I___

Application deadline: November 30

Office Use Only

Dec 2015

Page 82
 Attachments:

You must attach the following to your application:

1. A resume highlighting your involvement in enrironmental not-for-profit organizations.,

2. A letter of endorsement by a non-government organization,

3. A one-page summary (maximum 1000 words) outlining your interests and activities
and how you will use your consensus-building training.

Notification of results may be expected within 8 weeks after submission.

Declaration of Applicant

I HAVE READ THE INSTRUCTIONS, AND DECLARE THAT:

a. all information is true and complete and I understand it is subject to audit;

b. I agree to fulfill the commitments of any award made pursuant to this application;
c. I agree to allow my name and study plans to be released publicly if I receive this award; and
d. I authorize the release and exchange of my personal information by and between Student Aid Alberta
and any federal and provincial government departments or institutions to verify the information I have
provided to Student Aid Alberta and for the use in research and statistical analysis or in program evaluation
and program promotion.

I authorize Student Aid Alberta to release my name, award and home town if I receive an award.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 83
 Student Aid Alberta

Dr. Robert and Anna Shaw

Citizenship Award

Page 84
 Dr. Robert and Anna Shaw Citizenship Scholarship
This scholarship is named in honour of Dr. Robert and Anna Shaw, pioneers in the Sexsmith area. Dr. and Mrs. Shaw are
remembered for their many volunteer commitments to the community including serving on the local Board of Trade, Town Council,
School Board, teaching Sunday School and substituting for the minister. They were both willing to provide whatever assistance was
needed to help people with their problems.

The Dr. Robert and Anna Shaw Citizenship scholarship recognizes the academic and leadership accomplishments of students
graduating from Sexsmith Secondary School entering the fields of agriculture, engineering, fine arts or the trades.

Three awards of $500.

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Sexsmith Secondary School after September 1, 1996,
c. plan to enroll or be enrolled full-time in a post-secondary program related to agriculture, engineering, fine arts or the trades,
d. demonstrate a high academic standing in their Grade 12 year, and
e. demonstrate outstanding qualities in the areas of leadership, community spirit, involvement in extra-curricular activities
and a commitment to place the welfare of others above their own needs.

Selection Procedure
The selection committee will select recipients on the basis of demonstrated leadership, community involvement, participation in
extra-curricula activites.

Application Procedure

Submit completed application form and a summary of your leadership activities, community involvement, and extra-curricular
activities that demonstrate your community spirit and concern for others.

Students will be notified of the status of their application in September and the awards are issued in November after Alberta
Scholarship Programs confirms full-time enrolment of the successful candidates.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline: June 1

Page 85
 Dr. Robert and Anna Shaw Citizenship Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt, or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email

M <jay | myith | ^ yepr ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students arc not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____I____ ____i____ i____ i____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? | | Yes, what year__________ | | No

Are you a student at Sexsmith Secondary School? N

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month I year monthl year
____I____ ____ I____ I____ I____
Institution City Length of Program Year of Program

ED 2nd 3rd 4th

Office Use Only

60 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
Disbursement

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: April 2015

Page 86
 In two pages or less, please include a summary of your leadership activities,
community involvement, and extra-curricular activities that demonstrate your
community spirit and concern for others. You may include letters of
references to support your application.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by
and between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility
for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Advanced Education and Technology
and any provincial government departments, boards or institutions to verify the information I have provided to Alberta
Advanced Education and Technology, and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and hometown may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 87
 First Nations Colleges Health Careers Award
Student Aid Alberta Award Value - $2,000 per semester
The First Nations Colleges Health Careers Award is designed to encourage Indigenous Albertans (First Nations, Metis, and Inuit) to pursue
and complete post-secondary studies in certificate, diploma, applied degree, and bachelor’s degree programs in health careers in First
Nations Colleges in Alberta.

Indigenous Ancestry Requirements

You must be a Status Indian/First Nations, Non-Status Indian/First Nations, Metis, or Inuit and be able to provide proof of Indigenous
ancestry. Acceptable documents of proof include a copy of one of the following (do not submit original documents):
certificate of Indian Status, a status card or a valid band a certified copy of a Nunavut Trust Certificate card or Inuit
membership card beneficiary card
letter from your band verifying your status letter of support from Aboriginal Affairs and Northern
Metis membership card or letter issued by the Metis Nation Development Canada (AANDC) or Nunavut Tunngavik
you are registered with Incorporated
letter or membership card from the Metis Settlements for a non-status person, a letter of support from a First
General Council Nations, Metis or Inuit organization.
Other proof of Indigenous ancestry will be assessed on a case-by-case basis.

Residency Requirements Eligible Schools

You must be a Canadian Citizen or Permanent Resident of You must be attending one of the following First Nations
Canada and an Alberta resident. You are an Alberta resident Colleges in Alberta:
if one of the following describes your situation: • Blue Quills First Nations College
• you maintained permanent residence in Alberta for a • Maskwacis Cultural College
period of 12 months immediately prior to attending a post­
• Nechi Institute: Centre of Indigenous Learning
secondary school, or
• Old Sun Community College
• your parents or guardians have maintained permanent
residence in Canada for 12 consecutive months and reside • Red Crow Community College
in Alberta, or • Yellowhead Tribal College
• your spouse/partner is an Alberta resident, or
• you have been declared, or fall within a class of persons Credential Types
declared, to be a resident in Alberta by the Minister.
You must be enrolled in a certificate, diploma, applied or
bachelor’s degree program. Students enrolled in integrated
Course Load and Study Requirements training, pre-employment or non-credential programs are
not eligible.
You must be enrolled in the 2015-16 winter semester in order
to be considered for these awards.
You must be enrolled in at least 60% of a full course load.
Eligible Programs of Study
If you are a student with a documented permanent disability, Eligible programs are:
you can be eligible if you are enrolled in at least 40% of a full
• Addictions Counselling Indigenous Social
course load.
• Bachelor of Social Work Work Degree
Your school determines what constitutes a full-time course
• Health Care Aide Indigenous/Aboriginal
load in each program.
Social Work Diploma
Co-op students and students who are participating in an • Indigenous Addictions
Services Certificate Introduction to Addictions
official exchange may be eligible.
Counselling Certificate
You must be in satisfactory academic standing as determined • Indigenous Addictions
Services Diploma Licensed Practical Nurse
by your school - satisfactory academic standing may vary
in how it is determined by school or program. • Indigenous Health Traditional Social Work
You are not eligible to receive the award if you: Sciences Program
- switch your program of study from an eligible program
to an ineligible program before the award is paid, or Deadline and How to Apply
- withdraw from studies or drop from full-time to part-time The application deadline is February 12, 2016.
studies before the award is paid.
Submit your completed application to Student Aid Alberta.
Remember to include a copy of proof of your Indigenous ancestry
Number of Awards Issued with your application. Do not submit original documents.
If the number of eligible applicants exceeds the funding Student Aid Alberta
available for this award, a selection committee made up PO Box 28000 Station Main
of members from the First Nations College and Student Aid Edmonton AB T5J 4R4
Alberta will decide which applicants will receive the award.

Page 88
 First Nations Colleges Health Careers Award
Student Aid Alberta

FOIP Collection Notice

Advanced Education is collecting the personal information on this form under the authority of section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for the First Nations
Colleges Health Careers Award under the Student Financial Assistance Act and to administer scholarships including research, statistical
analysis and program evaluation. The use and disclosure of your personal information is managed in accordance with the FOIP Act.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, PO Box 28000 Station
Main, Edmonton AB T5J 4R4.

Indigenous Ancestry

Please indicate your Indigenous Ancestry:

□ Status Indian/First Nations □ Non-Status Indian/First Nations □ Metis □ Inuit

Documentation Requirements: You must provide proof of your Indigenous ancestry with your application. Acceptable documents
of proof include a copy of one of the following (do not submit original documents):
certificate of Indian Status, a status card or a valid band a certified copy of a Nunavut Trust Certificate card
membership card or Inuit beneficiary card
letter from your band verifying your status letter of support from Aboriginal Affairs and Northern
Metis membership card or letter issued by the Metis Nation Development Canada (AANDC) or Nunavut Tunngavik
you are registered with Incorporated
letter or membership card from the Metis Settlements for a non-status person, a letter of support from
General Council a First Nations, Metis or Inuit organization.

Other proof of Indigenous ancestry will be assessed on a case-by-case basis.

Personal Information

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) In itia l

Apartment or Box Number

□ Gender

Birthdate
□ Male

Day
□ Female

Month Year
__ I__ _l_____ l_ ___ I__

Street Address Are you an Alberta resident*? Q Yes □ No

* You are an Alberta resident if one of the following describes
your situation:
City/Town • You maintained permanent residence in Alberta for
a period of 12 months immediately prior to attending
a post-secondary school, or
Prov/State Country Postal/Zip Code
• Your parents or guardians have maintained permanent
_l_I— I—I—I— L J — I— I— I— L residence in Canada for 12 consecutive months and
Mobile Number (format: 999-999-9999) to receive text messages reside in Alberta, or
• Your spouse!partner is an Alberta resident, or
JL • You have been declared, or fall within a class of persons
Telephone Number (format: 999-999-9999) declared, to be a resident in Alberta by the Minister.
_L Alberta Student Number (if known)
Email Address

Citizenship Status: (check one)

□ Canadian □ Permanent Resident □ Protected Person

F IR S T N A T IO N S C O L L E G E S H E A L T H C A R E E R S A W A R D
L a s t re v is e d D e c e m b e r 2 0 1 5
Page 89
 Page 2
Full-time Studies Information

Name of School

Program

Program Specialization/Major

Program Outcome What year of this program will you be in? (check one)
□ Certificate □ 1st year or less □ 2nd year □ 3rd year Q 4th or 5th year
□ Diploma Length of your program of studies (check one)
□ Degree □ 1 year or less □ 2 years □ 3 years □ 4 or 5 years

Enter your program session start and end dates for the current school year.
Start End
Day Month Year Day Month Year

_ J __ J _____L l _ l_ J _____L I

Declaration of Applicant

I have read and understand the instructions, and declare that:
• all information provided is true and complete and I understand
it is subject to verification.
I agree to:
• immediately notify Student Aid Alberta if there are any changes
to the information I have provided in this application.
• provide information or documents as requested by Student
Aid Alberta to verify any statements made in this application.
• use any financial assistance provided to pay my academic
fees first; then I will pay other educational and living costs
associated with my program of studies.
I understand that:
• personal information pertaining to my enrollment and program
status will be released and exchanged between Student Aid
Alberta and the post-secondary institution I have indicated in
this application for the purpose of determining my eligibility
for the First Nations Colleges Health Careers Award.
• personal information may be released and exchanged
between Student Aid Alberta and any provincial government
department, board, or agency to verify the information I have
provided to Student Aid Alberta.
» I may be denied financial assistance if I fail to notify Student
Aid Alberta in writing of any change in my academic status
or study period, or fail to provide documents or information
as requested by Student Aid Alberta to verify statements
made in this application.
» if I make a false or misleading statement in this application
I may be denied financial assistance, and/or required to
immediately repay all financial assistance received, and/or
subject to criminal prosecution.
» failure to disclose information or provide updated information
as requested by Student Aid Alberta may constitute the
making of a false or misleading statement.
I understand and agree that:
• if I receive a scholarship my name, award, and city/town may
be released publically to promote the program. My name, the
name of the scholarship and the scholarship amount may also
be published on the Government of Alberta Grant Disclosure
Portal. However, my consent to the publication of this personal
information is not a criterion for eligibility, and if I do not want
to be identified, I will contact Student Aid Alberta and request
that it not be disclosed.

Signature of Applicant (in ink) Today’s Date (in ink)

Day Month Year
X _ u i l l i i i

OFFICE USE ONLY

130 13 1 2
GRANT TOTAL AWD INSTIT PGM DA MO YR DA MO YR ORG ADD
Disbursement E
MO YR AUTHORIZATION AWARD KEY APP KEY

Page 90
 Student Aid Alberta

Graduate Citizenship Award

 Graduate Citizenship Award
The Graduate Citizenship Award recognizes graduate students who have demonstrated outstanding dedication and leadership to
fellow students and to their community.

Eligibility Criteria
Applicants must:
a. be a Canadian Citizen, Permanent Resident or international student,
b. be living in Alberta at the time of the application deadline,
c. be currently enrolled full-time (a minimum 60% course load) in at least one semester of study in a graduate
program at one of the four Alberta universities in the year of application, and
d. be involved at the university, municipal, provincial, national or international level or in non-profit community
organizations.

Applicants who are currently receiving an honorarium for serving on committees may apply. An applicant cannot receive this award
twice for the same service commitments used in a previously successful application. International students must identify activities
that contribute to the Alberta community.

Value of Award - $2,000

Fifty (50) Alberta Graduate Citizenship Awards are awarded each year to be divided among the following universities in Alberta:

The University of Alberta - 20 awards, The University of Calgary - 20 awards

The University of Lethbridge - 5 awards Athabasca University - 5 awards

Application Procedure
Complete the application form and include two letters of support, a personal resume, proof of Canadian Citizenship, Permanent
Resident, or international student visa, proof of Alberta residency and a confirmation of full-time enrollment. Please refer to the
Terms of Reference for more information on the selection process.

Submit the application form and supporting documents to the Graduate Student Association (GSA). Questions on the application and
evaluation process should be directed to the GSA at your institution.

The Graduate Student Association will forward the names of successful candidates to Student Aid Alberta for processing. The
awards will be disbursed in December.

Information on other graduate awards administered by Alberta can be obtained at:

Contact: Student Aid Alberta Sendee Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

A p p lication D eadline is O cto b er 15

Page 92
 Graduate Citizenship Award
Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the
Freedom ofInformation and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your
eligibility for an award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships.
If you have any questions about the collection of this information, please contact Student Aid Alberta,
PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Return the completed form to your Graduate Student Association Office by October 15

Personal Information

Alberta Student Number (required lor processing) Social Insurance Number (required for processing)

Last Name (current legal nam e) Please use upper and lower case. First Name and One Initial (current legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Postal Code Area Code Telephone Number

Birth Date Gender (circle one) Alternate Telephone Number

I I M F
J ___ I___ l J __ I____I___ I___ l_ _ l
day month year

CITIZENSHIP (check one) Email Address:

CANADIAN CITIZEN or

PERMANENT RESIDENT (Landed Immigrant) or Have you lived in Alberta all your life? j Y j N
□ Include a photocopy of permanent resident card.
N ote:

INTERNATIONAL STUDENT
If no, since
M onth Year

□ N ote: Include a photocopy of your student visa.

POST-SECONDARY STUDIES
Name of Institution____________________

Student ID Number:____________________________ Start Date of Program

Office Use Only

Oct 2015

Page 93
 Application Procedure
Complete the application form, and include the following:
Two (2) letters of support which addresses your service and community engagement efforts,
Curriculum Vitae which provides a brief description of your responsibilities associated with each activity,
*Proof of Canadian Citizenship or Permanent Resident Status such as a copy of birth certificate or passport, or
permanent resident card; copy of student visa if international student,
* Proof of Alberta residency - government issued ID, a third party lease agreement, a letter from an Alberta based
employer, a utility bill, etc. and,

v *Confirmation of full-time enrollment.

J

r Declaration of Applicant
" \

I have read and understand the instructions, and declare that:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic records may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for an award,
b. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta and
for the use in research and statistical analysis and program evaluation, and
c. iff receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility and if I do not want to be identified I will contact Student Aid Alberta..

Signature of Applicant (in ink) Date (in ink)

V J

Information on other graduate awards is available at:

Student Aid Alberta

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Page 94
 Student Aid Alberta

International Education
Awards Ukraine

Page 95
 International Education Awards - Ukraine

This award was designed to enable post-secondary students, post-graduates, professionals and scholars to undertake career-related
training, research or study in Ukraine, and Ukrainian post-secondary students, post-graduates, professionals and scholars to
undertake career-related training, research or study in Alberta.

The bursary was created in 2003 with a $500,000 endowment in support of Alberta Advanced Education’s international education
strategy.

Eligibility Criteria
Canadian Citizens/Permanent Residents: Applicants must be Alberta residents, preferably attending or associated with an
Alberta post-secondary institution or apprenticeship/co-op program. Applicants must be either enrolled in a post-secondary
institution at a senior level, a graduate student, a recent post-graduate, or a professional or scholar. Students applying to take a
course or applying to study for one or two semesters at a post-secondary institution in Ukraine are also eligible.

Ukrainian residents: Applicants must be citizens or residents of Ukraine, preferably attending or associated with a post-secondary
teaching or research institution or apprenticeship/co-op program. Applicants must be either enrolled in a post-secondary institution
at a senior level, a graduate student, a recent post-graduate, or a professional or scholar. Students applying to take a course or
applying to study for one or two semesters at a post-secondary institution in Alberta are also eligible.

Selection Procedure
Recipients will be selected by a selection committee representing Alberta post-secondary institutions and the Alberta Ukrainian
community. Selection will be based on academic merit, past accomplishments, the purpose or validity of the proposal, reference
letter, and institutional support and benefit to the recipient’s institution.

Please refer to the Terms of Reference posted on the website for selection and scoring details.

Up to five awards of $5,000 (Canadian funds) are available each year.

Application Procedure
Include with your application a resume, an official transcript and essay describing the program or research, a letter of support from
the host institution and a letter of reference.

Incomplete applications will not be submitted to the committee.

Submit completed application to Student Aid Alberta: Mail to:

Student Aid Alberta
Box 28000 Station Main
Edmonton, AB T5J 4J4

Faxed applications are not accepted.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

All supporting documents must be in English and all translated information must be certified.

For information of this award and other scholarships:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Application deadline is February 1.

Page 96
 International Education Awards - Ukraine
Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom o f Information and
Protection o f P rivacy A ct (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the Alberta Heritage
Scholarship A ct and to administer Alberta Scholarships, If you have any questions about the collection of this information, please contact Student Aid
Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4,

Personal Information
Social Insurance Number (Albertans only)

Last Name (current full legal name) First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Province Postal Code Area Code Telephone Number

CITIZENSHIP (check one)

| CANADIAN CITIZEN [ ]CITIZEN OF UKRAINE PERMANENT RESIDENT
Note: Attach a photocopy of permanent resident card.
Place of Birth

Have you lived in Alberta or Ukraine all your life L YES

z NO If no. since (M o n th . Year)
____ I____ ____ I_____I_____I____

Gender (circle one) Birthdate (D a y, M o n th , Year) ______ Email Address

M F
__ I___I___I___I___I___I___I__

Please ensure your application is complete and submitted by February 1.

Application must include your resume, official transcript and essay describing the program or
research, a letter of support from the host institution and letter of reference.
All documents must be in English.

Office Use Only

Revised: Dec 2015

Page 97
 Proposed Program
What type of program will you be enrolled in?
Internship j j Co-Op | | Practicum j j Apprenticeship j j Research Other

Name of the host institution (i.e. the school you plan on attending) Program start date: day/month/year

_______________________________________ I i I i I i i i
Address of the host institution Program end date: day/month/year

J___ ___ I___ ___ I___ I___ L

Name of person coordinating your program at the host institution Telephone Number

Include a letter of support from the above mentioned institution.

Additional Supporting Documents

Statement of Intent/Essay:
In two pages or less, please provide a detailed description of your proposed program of study or research project and how your
internship, practicum, co-op program, research project or program could benefit Ukraine and Alberta. Also, include what you
plan to accomplish during and after your studies.

Reference:
Please attach a reference letter which should comment on your academic record and assessment of the merits of the proposal or
program. The reference should be from an individual who is familiar with your academic career and must include the name,
title/position, address, telephone number and email address of the individual providing the reference.

Education Information:
Please attach a one page educational resume listing schools you have attended and programs taken, including degrees,
diplomas, and certificates earned. Attach your most recent transcript or statement of marks and a letter indicating the
involvement and support for the program or project from the host institution.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete, and I understand it is subject to audit,
b. I will be a student taking the internship/co-op/practicum/apprenticeship described above or conducting research,
c. I will notify Student Aid Alberta in writing if I withdraw before completing my program.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my program enrolment status may be released and exchanged by and between
Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship, and
b. if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Page 98
 Student Aid Alberta

Jo-Anne Koch Action for

Bright Children Society Awards

Page 99
 Jo-Anne Koch Action for Bright Children (Calgary) Society Awards

Named in honour of Jo-Ann Koch, the first Principal of ABC (Westmount) Charter Public School in Calgary. As a parent of a gifted
child, and a long-time educator in Alberta’s publicly-funded schools, Ms. Koch was a tireless advocate for the rights and needs of
gifted learners..

Award Value

Up to two awards - S500 each

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Permanent Resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have completed Grade 12 requirements at a publicly funded Alberta high school,
c. meet the criteria for Giftedness as determined by his/her school jurisdiction, and,
d. plan to enroll or be enrolled full-time in a post-secondary program.

Application Procedure
Application forms are available from high school counsellors and on the Student Aid Alberta website. Applicants must mail in
application forms with the following attachments, unstapled:

* submit a 150-250 word personal statement outlining how you perceive your Giftedness as you embark on
your post-secondary education journey, and
* include a letter of support from your high school.

Students must mail their applications to: Student Aid Alberta

PO Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Incomplete applications will not be submitted to the committee. Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Selection Criteria
A selection committee established by the Action for Bright Children (Calgary) Society will select the recipients. Selection will take
into consideration the following:

* The strength of the school recommendation as determined by the letter of support from the Administration or Counselling
Department, and
* The strenght of the student’s 150-250 word essay.
* Preference will be given to applicants who have received extra support for their learning needs.

To recognize the historic connection between th ABC (Calgary) Society and Westmount Charter School, one recipient will be
selected from Westmount Charter School in Calgary. In the event there is no suitable candidate from Westmount Charter School,
both awards will be offered to qualified students from other Alberta High Schools.

For information on this award and other scholarships:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Application Deadline: April 1

Page 100
 Jo-Anne Koch Action for Bright Children Society Awards

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mai ling Ad Ires S (III ;ludc Apt. or Box N umbe D City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M djiy | mopth | [ ytjar ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Anach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____ 1____ ____ 1____ 1____ 1____
I f y ou h av e a n sw e re d “ N O ” to one o f th e A lb e rta R e sid en c y q u e stio n s , p lea se in c lu d e a le tte r e x p la in in g th e tim e s p e n t in A lb e rta
as a n o n fu ll-tim e s tu d e n t.

Name of high school you graduated from: __________________________________________________

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month I year month I year
I 1 _ J___

Institution City Year of Program

0 2nd 3rd 4th

Dffice Use Only

121 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Jisbursement E

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: Jan. 2016

Page 101
 Personal Statement

Include with your application:

1. A 150-250 word personal statment outlining how you perceive Giftedness

as you embark on your post-secondary education journey.

2. A letter of support from your school.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to verification,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing
one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and
between Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of determining
my eligibility for a scholarship,
c. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however,
this is not a criterion for eligibility, and if I do not want to be identified, I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 102
^AibeA* ja
STATUTORY DECLARATION - Cheque has been cashed.
This form should be completed in handwriting.

I , _____________________ ______ ______________________ _________________________________________

(Full Name of Payee) Please print
o f ________________________ __________________________ _ _____________________________
(Street Address, City/town, Province)

do solemnly declare:
I. That I am the named payee on cheque numbered _________ _ d a te d _________ for the amount of ______

issued by HER M ajesty the Queen in right of the Governm ent o f Alberta, M inister o f Finance, hereinafter referred

to as ' the original cheque".

II That I have not benefited either directly or indirectly by the proceeds of the original cheque.

fll. That I have examined the original cheque or a photocopy of the original cheque, showing an endorsement of my
name.

IV. That the following are two specimens o f my signature: __________ _ _ _ _ _ _ _ _ _ _ _ _________
(Signature)

(Signature)

V. That the answers to the questions below are given by me and are true to the best o f my knowledge, information

and belief.
(1) Did you receive the origina! cheque or did you ever see it? _____________________________

(2) If you did receive the original cheque, or if you ever saw it, please explain the facts of circumstances that led
to its lo s s .___________________________ ______________ _________

(3) Did you endorse the original cheque? _______________ __________ ______________________ _

(4) Was the endorsem ent o f your name on the original cheque made with your consent or by agreement or

understanding with anyone? _____________ __________________________

(5) If you did not receive the original cheque, do you know who received the original cheque or who endorsed

your name on it or who received any benefit in money or credit or anything o f value from the cashing of the
original cheque? (Please provide details.)

(6) Where do you usually cash your cheques?

the personal information being collected on this form is collected tor the purposes of validating a claim for a lost, destroyed or stolen payment and
re-issuing funds. The information may also be used for law enforcement purposes. The collection is authorized under sections 33(b) and (c) of the
Freedom o f Information and Protection o f Privacy A ct and will be managed in accordance with the provisions under the Act. If you have questions
about the collection of this information, please call Student Aid Alberta, Privacy Officer at 7G0-427-9639. You can also mail your questions to
Student Aid Alberta. Executive Services, PO Box 2HOOO Stn Main, Edmonton AB T5J 4R4.

Page 1 of 2

Page 103
 (7) Are you known in the financial institution or place w here the original cheque was cashed?

(8) What was your mailing address on the date the original cheque was due to arrive?

(9) What are the nam es and addresses, and relationship to you, of any persons w ho resided with you at the

time, at the address described in number (8)? __________________ _________________________________

(10) Where and with whom did the Postal employee leave your mail? Also state your forwarding address, if one

was u s e d .______________________ _________________ ________________

(11) Do you have any reason to believe that the cheque was endorsed or that the proceeds of the original cheque

were received by any member o f your family, by any associate or by any other person whose name is listed

in the answer to num ber (9)? _________ _ _ _ _______ _

(12) Do you have knowledge of any other facts or circumstances that led to the loss, theft, or cashing of the

original cheque? ______________ _______ ________________________ __________________________ _

if so, please provide details: _______________________ __________________________ ___________ __

(13) I have asked Alberta Innovation and Advanced Education (Student Aid) to issue a new cheque to replace the
original cheque.

AND I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it is o f the same

force and effect as if made under oath

DECLARED before me at th e _____________ of

in the Province of _____________________________

this __________day of ___ ____________ 20________ .

(Commissioner for Oaths in and for the Province o f Alberta) (Signature of Payee)

PRINT NAME OR STAMP HERE _ _ _ _ _ _ _ _ _ _

Appointment Expires _______ , 20

The personal information being collected on this form is collected for the purposes of validating a claim for a lost, destroyed or stolen payment and
re-issuing funds. The information may also be used for law enforcement purposes. The collection is authorized under sections 33(b) and (c) of the
Freedom o f Information and Protection o f Privacy A ct and will be managed in accordance with the provisions under the Act. if you have questions
about the collection of this information, please call Student Aid Alberta, Privacy Officer at 7B0-427-9C39. You can also mail yuut questions to
Student Aid Afberta, Executive Services, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Page 2 of 2

Page 104
REPLACEMENT CHEQUE

ORIGINAL CHEQUE REPORTED AS:

o NEVER RECEIVED
o LOST
o OTHER

I UNDERSTAND THAT IF I CASH OR USE CHEQUE # FOR PAYMENT, I MAY BE CHARGED

WITH A CRIMINAL OFFENCE

REPLACEMENT CHEQUE

ORIGINAL CHEQUE REPORTED AS:

o NEVER RECEIVED
o LOST
o OTHER

I UNDERSTAND THAT IF I CASH OR USE CHEQUE # FOR PAYMENT, I MAY BE CHARGED

WITH A CRIMINAL OFFENCE

REPLACEMENT CHEQUE

ORIGINAL CHEQUE REPORTED AS:

O NEVER RECEIVED
o LOST
o OTHER

I UNDERSTAND THAT IF I CASH OR USE CHEQUE # FOR PAYMENT, I MAY BE CHARGED

WITH A CRIMINAL OFFENCE
 REGISTER OF RETURNED CHEQUES 5140

Page 106
DATE:...

R EC ’D BY:_

STUDENT N AM E CHEQUE # S.I.N. C H EQ U E DATE AM O U N T IN S T IT U T IO N /B A N K DISPOSITION

DATE REASON CODE

REASON CODES: (1) 4th FLR. CAP. HEALTH CENTRE (CER) (2) REM AILED TO SCHOOL (3) SAASC (4) P.C.& L UNIT (5) OTHER (6) REMAILED TO STUDENT
 PO Box 28000 Stn. Main
S tu d e n t A id A! h a rt a Edmonton, Alberta T5J 4R4
Canada

<Date>

Attn: Awards Officer/Registrar

The attached report is a listing of students who have qualified to receive a SCHOOL
NAME and have indicated they are attending your school.

In order to receive payment of this award, students must be enrolled in full-time studies
defined as taking a minimum 60% full course load, or greater in a health-related program
of study.

Please complete the attached Declaration of Enrollment report by placing an “X ” in the

“Confirm” column beside the name of the students enrolled full-time at your school. If
a student is not attending, or attending part-time, please indicate this in the "Comments"
column. Each student shown on the report has signed a Declaration of Applicant form
authorizing the release of their enrollment status. See attached Declaration of Applicant
Sample for your reference.

In order to allow sufficient time to process the payment, please return the signed
Confirmation of Enrollment Declaration and the completed Declaration of Enrollment
report to our office within 15 days of the date of this letter.

I hereby declare that the students listed on the attached Declaration of Enrollment report
are currently enrolled in full-time studies as defined above:

Signature of School Official Title

Printed Name of School Official Institution Name

Today’s Date Phone Number

Note: The information in this report is to be used solely for purposes of verification of student information and
adm inistration o f S tudent Aid Alberta Program s

Page 1 of 2
Page 107
C o m p le te th e fo rm and fo rw a rd to S tu d e n t A id A lb e rta via either:

Mail: Student Aid Alberta Fax:780-415-0448 Scan & email: COR-AB@qov.ab.ca

Program Payments & Revenue Support
PO Box 28000 Stn. Main
Edmonton, Alberta T5J 4R4
Canada

S ho u ld you re q u ire fu rth e r in fo rm a tio n , p le ase c o n ta ct us at:

T: 780 4 2 7 -5 5 6 8

T h a n k you,

P rogram P a ym e n ts & R e ve n u e S u p p o rt

Enclosures

Page 2 of 1

Page 108
 SCHOOL NAME
STUDENT AID ALBERTA
DECLARATION OF APPLICANT
SAMPLE ONLY
Declaration of Applicant
1 i h * tv s r e a d a rv d u n d e r s t a n d th e in s t r u c t io n s , a m i c fe d a rw t lx jt :
j A id A lb e r ta in w r itin g o f a n y c h a n g e in m y a c a d e m ic s ta tu s
* a ll in fo r m a tio n p r o v id e d is tru e a jid c o m p le te a n d i u n d e rs to o d
it is s u b je c t to v e rific a tio n .
I a g re e to :
* im m e d ia te ly n o t if y S tu d e n t A id A lb e rta it th e re a re a n y c h a n g e s
t o th e in fo r m a tio n \ h a v e p r o v id e d in this; a p p lie d io n ,
* p r o v id e in fo r m a tio n o r d o c u m e n ts re q u e s te d b y S tu tfs r ii
A id A lb e r ts to v e r ity a iry s t a te m e n ts m a d e in t h is a p p lic a tio n .
* u s e a n y fin a n c ia l a a s i ^ t r o e p r o v id e d to p a y m y a c a d e m ic
lo o s firs t: th e n I w ill p a y o t h e r e d u c a tio n a l a n d liv in g c o s ts
a s s o c ia te d w it h m y p r o g r a m o f s tu d ie s *
J u n d a rs ta rx J th a t;
* p e rs o n a l in fo r m a tio n p e r ta in in g to m y n iu c H m c n r p r o g ra m
s la te s w ifi b o re le a s e d a n d e x c h a n g e d b e tw e e n S tu d e n t A id
A lb e r ta a n d th e p o s t - s e c o n d a r y in s tru c tio n I h a v e in d ic a te d in
th is a p p lic a tio n f o r th e p u r p o s e o f detorm issinp ' m y e lig ib ility
f o r t h e f ir s t N a tio n s C o lle g e s H e a lth C a re e rs A w a rd ,
* p in io n ? I in fo r m a tio n m a y b e re le a s e d a iid e x c h a n g e d
b e tw e e n S tu d e n t A id A lb e r ta a n d a n y p ro v in c ia l g o v e rn m e n t
d e p a r t m e n t b o a rd s o r a g e n c y t o v e rify th e in fo rm a tio n I h a ve
p r o v id e d t o S t u d e n t A id A lb e rta .
j S ig n a t u r e o f A p p lic a n t (in kifc)
* I m a y b e iie n ? e d frnarroiaJ a s s is ta n c e if i fa il to n o tify S tu d e n t
o r s tu d y p e r io d , o r fa il to p r o v id e d o c t im e r it s o r in fo n n a tio n
a s r e q u e u e d h y S tu d e n t A id A lb e rta to v e r ify s ta te m e n ts
m a d e in th is a p p lic a tio n ,
* If l m a k e a f a ls * o r m is le a d in g s t a te m e n t in t h is a p p lic a tio n
1 m a y b e d e n ie d fin a n c ia l a s s is ta n c e , a n d /o r r e q u ire d to
im m e d s a te ly r e p a y a ll fin a n c ia l a s s is ta n c e re c e iv e d . a n d /o r
s u b je c t t o c r im in a l p r o s e c u tio n .
* fe ifu ie t o d u s d c & o in to rm a tro n o r p r o v id e u p d a te d in fo rm a tio n
a s r e q u e s te d b y S to d e n f A id A lb e r ts m a y c o n s t it u t e th e
m akin ig o f a fa ls e o r m is le a d in g s ta te m e n t.
! understand and agree
• i t s r e c e iv e a s c h o la r s h ip m y n a m e . av^ard. a n d c ity /to w n unay
b o re lo u s e d p u b i b a lly t o p r o m o te th e p ro g ra m . M y n a m e , th e
n a m e o f The s c h o la r s h ip a n d th e s c h o la r s h ip a m o u n t m a y e ls e
b e p u b lis h e d o n The G o v e rn m e n t o f A & e r ta G ra n t D ps c lo s u re
PorU ir. H o w e v e r, m y c o n s e n t t o th e p u b lic a tio n o f th is p^rs<onai
in fo r m a tio n is n o t a c rite rio n f o r e lig ib ility , a n d if I d o n o t w a n t
in b e id e n tifie d , I w ill c o n ta c t S tu d e n t A id A lb e rta a n d re q u e s t
th a t it r o t b e d is c lo s e d .
T o d a y 's D a te { in in k )
O-sy V o-ith Y%^r ■
 Page 110
<DATE:>
SCHOOL NAME
<SCHOOL CODE AND NAME >
DECLARATION OF ENROLMENT

FALL 2015 WINTER 2016

AWARD ID FIRST NAME SURNAME ASN BDAY GRNTAMT CONFIRM X CONFIRM x COMMENTS
 ADJUSTMENT TO ACCOUNTS REFERRED FOR COLLECTIONS
PROGRAM PAYMENTS & REVENUE SUPPORT

NAME:

SJ.N.:

ACTION REQUIRED:

RECALL DEBT:

$ Referral Code Referral Date

ADJUSTMENT Please reduce the original principle from $5,880.00 to $4,485 00 due to appeal granted

From $ to Referral Code Referral Date

From $ to Referral Code Referral Date

ADJUSTMENT Student appealed their over-award(), adjust principal

From S to $ Referral Code Referral Date

From $ to $ Referral Code Referral Date

ADJUSTMENT OTHER:

From $ to $ Referral Code Referral Date

From $ to $ Referral Code Referral Date

COMMENTS:
NOTE:

REQUESTED BY: ____________________________________________ ___________________________

Print Name Date (mm/dd/yy)

AUTHORIZED BY: ____________________________________________ ___________________________

Supervisor -Program Payments & Revenue Support Date (mm/dd/yy)

Page 111
 Student Aid Alberta

Laurence Decore Award

for Student Leadership

Page 112
 Laurence Decore Award For Student Leadership

The Laurence Decore Award for Student Leadership honours Mr. Laurence Decore, former Edmonton
mayor and leader of the Alberta Liberal party.

The original proposal for the Student Leadership Awards was initiated by the Alberta College & Technical
Institute Student Executive Council (ACTISEC). The Awards are intended to recognize post-secondary
students who have demonstrated outstanding dedication and leadership to fellow students and to their
community.

Award Value - $1,000

Eligibility Criteria
Nominees must be:
a. a Canadian Citizen or Permanent Resident and be an Alberta resident,
b. currently enrolled full-time (a minimum 60% course load) in an undergraduate program at a
designated Alberta post-secondary institution,
c. involved in either student government or student societies, clubs or organizations, or involved in
student organizations at the provincial or national level or in non-profit community organizations,
d. selected by a Selection Committee at the educational institution.

Selection Procedure
Each post-secondary institution is responsible for establishing a Selection Committee to review
applications.

The Selection Committee will forward the names o f successful candidates to Student Aid Alberta no later
than March 1st.

Application Procedure
Include with your application:
a. A detailed description o f your involvement and accomplishments in student government or student
societies, clubs or organizations, or student organizations at the provincial or national level or in
non-profit community organizations, and
b. A related letter o f reference.

Deadline:
Students must submit completed applications directly to Student Awards Offices
at their schools by the posted application deadline.

Page 113
 Laurence Decore Award For Student Leadership

^Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information^
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Important: Return the completed application package to the Student Awards Office.

Personal Information
Alberta Student Number (go to www.education.gov.ab.ca to find your ASN or lo obtain one) Social Insurance Number (required for processing) \

Last Name (current legal nam e) Please use upper and lower case. First Name (current legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Postal Code Area Code Telephone Number

Birth Date Gender (circle one) Email Address

day month
J ____I____L
year
0 0
CITIZENSHIP (check one)
] CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta?
N

Llave you lived in Alberta all your life?

N Since IF YOU ANSWERED “NO” TO BOTH QUESTIONS, PLEASE INCLUDE A
J ___ I___ L LETTER EXPLAINING WHAT YOU HAVE DONE SINCE ARRIVING IN
month year
ALBERTA, e.g. attending school, working, etc.
POST-SECONDARY STUDIES
Name of Institution

Location Entry Date of Program_

Office Use Only

89 8 0 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR

Disbursement

$1,000 MO YR ASP AUTHORIZATION AW ARD KEY APP KEY

Revised: Jan. 2016

Page 114
 r *
Please submit a detailed description of your involvement and accomplishments in
" \

student government or student societies, clubs or organizations, or student

organizations at the provincial or national level or in non-profit community
organizations, and
*
Include a related letter of reference.
J

r
Declaration of Applicant
I have read and understand the instructions, and declare that:
a. all information provided is true and complete and I understand it is subject to verification,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing
one semester.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic records may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a
scholarship,
b. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta and for
the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however this
is not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

V j

r A,
To Be Completed By Post-Secondary Institution:

I hereby declare that this student has been selected for a Laurence Decore Award for Student Leadership
and is currently enrolled or was enrolled full-time, i.e. taking a minimum o f a 60% full course load at
this institution for one semester during the current academic year - September to April.

Name (please print) Position

Signature
V _______________________________________________________________J

Further information on other awards can be obtained at: studentaid.alberta.ca/scholarships

Page 115
 V BURSARY PARTNERSHIPS PROGRAM

Northern Alberta Development Council (NADC) encourages employers and community organizations to invest in
the future of northern Alberta by sponsoring a return service bursary for post-secondary students. The NADC Bursary
Partnerships Program will match between $1,000 and $3,000 per student - to a total of $6,000 per student. Higher
matching funds are available for pharmacy or large animal veterinary students ($6,000 per year), nurse practitioner
students ($9,000 per year), and medical or dentistry students ($12,000 per year). Sponsors may provide a bursary
amount that is higher than our matching fund limits. (New sponsors, please contact the NADC to set up a
Partnerships Bursary).

Sponsors can provide a bursary to a student for a number of years or can sponsor a number of bursaries in one year
to different students.

Student Selection Process

The sponsor selects the student for their portion of the funding. These businesses and organizations usually
advertise through local newspapers, various educational institutions or places of employment. Students must
complete the Bursary Partnerships Program Student Application and submit to the sponsor for selection.

The sponsor submits the student’s application to NADC for consideration of matching funds. In addition to the
sponsor’s criteria, applications will be reviewed by the NADC for the following criteria
■ Students must be a resident of Alberta for 12 consecutive months before the start of you program
■ Students must be enrolled full-time in a post-secondary program designated by Enterprise and Advance
Education
■ Students must not be in default of a provincial student loan
■ Students must be at arm’s length to the sponsor (not related and also selected through impartial means)
■ Students must have reasonably good prospects for employment in northern Alberta upon graduation
■ Students cannot receive both the NADC Bursary and the Partnerships Bursary during the same school year
■ Students can receive more than one Partnerships Bursary; however, the total matching funds from NADC
cannot exceed $3,000 in the same academic year.

Return Service Commitment

■ Innovation and Advanced Education will send the student a contract to commit to live and work anywhere in
northern Alberta upon graduation (one month of return service is required for each $500 of total bursary
support).
■ If the sponsor plans to employ the student following completion of studies, the sponsor can also sign a
contract with the student and can tailor the contract to suit the organization or company’s needs.
■ Recipients who do not meet the return service commitment must repay the bursary. Please note that
Innovation and Advanced Education can only recover their portion of the funds, and cannot recover funds on
behalf of a sponsor.

Visit www.benorth.ca for applications

and bursary information

benorth (780) 624-6545 (toll free first dial 310-0000)

beUnu Opportunity
V V X 7 North

Student: Send your original application to your Bursary Partnerships Program

sponsor. DO NOT mail to NADC.

Sponsor: Application must be submitted by November 30th, of the academic year for which
the bursary is awarded.
Send the student’s original application and ‘Sponsor Request for Matching Funds’ to:
Northern Alberta Development Council
Postal Bag 900 - 14
Peace River, AB T8S 1T4
 This page is for reference only. Do not send this page with your application.

Please enter the code for your institution and program in Section 3 on Page 1 of the application.
If your institution or program is not listed here, leave the space blank.

INSTITUTION CODE LIST

University Codes
2204 Athabasca University 2203 University of Lethbridge
2246 Concordia University College of Alberta 2243 Mount Royal University
2247 Grant Mac Ewan University 5410 University of Northern British Columbia
2255 Kings University College 2301 University of Regina
2201 University of Alberta 2302 University of Saskatchewan
2101 University of British Columbia 2511 University of Toronto
2202 University of Calgary 2106 University of Victoria

College and Technical School Codes

5110 Alberta College of Art & Design 2226 NorQuest College
1255 Blue Quills First Nations College 2221 Northern Alberta Institute of Technology (NAIT)
2218 Bow Valley College 2020 Northern Lakes College
2245 Canadian University College 2224 Olds College
2241 Grande Prairie Regional College 2007 Peace River Bible Institute
2230 Keyano College 2219 Portage College
2225 Lakeland College 5677 Professional Medical Associates - St. Albert
2220 Lethbridge College 2244 Red Deer College
2242 Medicine Hat College 2222 Southern Alberta Institute of Technology (SAIT)

PROGRAM CODE LIST

University Codes
548 Aeronautical Engineering 523 Forestry 507 Pharmacy
520 Agriculture 542 General Studies 530 Physical Education (Kinesiology)
521 Architecture 506 Graduate Studies (Masters) 562 Post Diploma Nursing
525 Arts 524 Home Economics 510 Post Graduate Studies (Doctorate)
533 Business Administration/Commerce 525 Humanities 540 Recreation Administration
522 Dental Hygiene 501 Law 534 Rehabilitation Medicine
503 Dentistry 508 Master Business Admin. (MBA) 532 Science
525 Economics 527 Medical Lab Science 525 Social Science
537 Education 500 Medicine 535 Social Work
531 Engineering 528 Nursing 536 Theology
526 Fine Arts 504 Optometry 502 Veterinary Medicine

College and Technical School Codes

561 Accounting 578 Electrical Engineering 528 Nursing (Degree)
520 Agriculture 136 EMT - Ambulance 650 Office Administration
600 Animal Health Technology 904 EMT - Paramedic 507 Pharmacy
577 Architectural/Structural Engineering 624 Engineering Design/Drafting 530 Physical Education
521 Architecture 523 Forestry 580 Power Engineering
525 Arts 542 General Studies 420 Practical Nurse / LPN
612 Arts & Design 565 Health Sciences 585 Radio/Television/Broadcast Arts
541 Aviation & Related Technologies 681 Heavy Equipment Operator 540 Recreation Administration
568 Beauty Culture 524 Home Economics 534 Rehabilitation Medicine
609 Biological Sciences 609 Hospitality Services 615 Rehabilitation Services
533 Business/Admin/Commerce 628 Instrumentation Engineering 571 Religion (Certificate or Diploma)
576 Chemical /Mineral Engineering 573 Journalism (Diploma) 532 Science
575 Civil Engineering 596 Legal Assistant/Court Reporter 574 Secretarial Arts
586 Commercial Cooking/Baking 594 Law Enforcement 535 Social Work
566 Community Services 644 Legal Secretary 614 Teacher’s Assistant
563 Computer Technology 642 Massage 630 Telecommun. Engineering Tech.
622 Dental Assistant 579 Mechanical Engineering 611 Theatre Arts
522 Dental Hygiene 593 Mechanics 536 Theology (Degree)
572 Early Childhood Education 610 Music 595 Travel/Tourism
537 Education 562 Nursing (Diploma) 616 Visual Arts/Communication
Page 117
 Bursary Partnerships Program Student Application
We are collecting this personal information under the authority of the Students Finance Act, to determine and verify your eligibility for a
bursary under the Act. Your personal information is protected by the privacy provisions of the Freedom of Information and Protection of
Privacy Act. If you have any questions about the collection of this information you may contact the Alberta Scholarship Programs office
at 9940 106 Street, Edmonton, AB T5K 2V1, or phone 780-427-8640 (toll free by first dialling 310-0000).

Please com plete in ink Alberta Student Number Social Insurance Number
I I I I I I I I I l l
Section 1 C O N T A C T IN FO R M A TIO N
Last Name First Name
| | |
I I I I
Apartment or Box Number Street Address
|
I I | I I
Town or City Prov. Country Postal Code
I I I I I I I I
Email Address Home Phone Number Cell Phone Number
I I l l I I I l I l l I l l l l l

Section 2 P E R S O N A L IN F O R M A TIO N
Citizenship (Visa students are not eligible) □ Canadian Citizen □ Permanent Resident □ Convention Refuqee
(Landed Immigrant)_____
Month Year
Have you lived in Alberta all your life? LI Yes U No, since: I | Gender □ Male G Female
0 t Day Month Year
Are you an Aboriginal Student □ Yes G No Birthdate | ^

Section 3 E D U C A TIO N A L IN FORM A TIO N

Name of Post-Secondary Institution Institution Code Program Code (seepreviouspage)
Town /City Campus Name (if not attending main campus)

Program Enrolled in (be specific) Program Type Cl Diploma G Masters

G Certificate Cl Degree G PHD
/
Major Minor Student Identification Number (fromtheschool youwill attend)
What year of your program n n n i-» . n Length of program □ Q1 Q Q Q
are you entering? 1—1 1 I—I 2 U 3 U 4 I_I5 in years L_1 LJ J ^ u jd
Dates you will be attending school in the upcom ng school year When will you complete your program?
Day Month Year Day Month Year Day Month Year
From: Date | 1 | 1 | | |
T°: I I I I l I I I
Month Year
When will you be available for work?

Have you answ ered A LL the q u e stio n s?

FOR OFFICE USE ONLY
TO TAL A W A RD INSTIT. PG M . DAY MO. YEAR DAY MO. Y E AR W KS. YR LENGTH

ORI. ADD DAY MO. YEAR AW ARD KEY APP KEY

E
AS P A u th o riz a tio n

April 2015 APP-TYPIF21

Page 1 of 4

Page 118
Section 3 (Continued) (Optional)
Latest high school average % or Latest Grade Point Average out of (Attach a printout of your latest unofficial transcript
or a copy of your latest official transcript)

Are you repeating a year of study? Q Yes □ No

Previous Post-Secondary Education

Institution Program Degree Years Completed

Section 4 FIN A N C IA L IN F O R M A TIO N (Optional)

If you are a SINGLE student, please indicate if you are living with parent(s) during your post-secondary studies? □ Yes □ No

MONTHLY EXPENSES (while in school) MONTHLY RESOURCES (while in school)

Rent / Mortgage payment Wages / Salary after deductions

Utilities (power, heating, water, phone) Spouse’s income after deductions

Food / Clothing / Personal Care Contributions from parents

Transportation Child support / alimony

Training allowance
Child care / Babysitting
List:
Additional expenses (i.e. medical) Government funding (excluding loans
List: and lines of credit) List:

Total monthly expenses Total monthly resources

ANNUAL EDUCATION EXPENSES OTHER RESOURCES
Tuition Savings when you start school
Other funding, grants or scholarships (excluding
Fees
loans and lines of credit) List:
Books / Supplies / Instruments

Total education expenses Total other resources

ASSETS Value VEHICLE(S) year / make / model Value

Registered Retirement Savings Plan

Assets (i.e. term deposits, bonds, stocks)

Total assets Total current value of vehicle(s)

Have you answered ALL the questions?

Page 2 of 4
Page 119
Section 5 R E S ID E N C E (Optional)

What do you consider your home community? (This information may be publicized with your name)

Number of
List where you have lived in northern Alberta From To
years

Total years in northern Alberta

Section 6 E M P L O Y M E N T IN N O R T H E R N A L B E R T A (Optional)

List periods of employment in northern Alberta (Complete this even if you have indueted a resume)
Number of years
Employer Location Phone Type of work
Full-time Part-time

Total years in northern Alberta (Full-time and Part-time)

Section 7 S TU D E N T REM ARKS

The NADC Bursary Partnerships Program is intended to attract graduates to live and work in northern Alberta. Bursary recipients must
live and work in northern Alberta within six months of graduation. The Return Service Obligation is one full-time month (or equivalent) for
every $500 of bursary funds received. Students who do not work in the north will be required to repay the bursary.

What are your main reasons for wanting to live and work in northern Alberta?

Outline the employment opportunities you see in northern Alberta in your field of studies:

Section 8

Please indicate how you heard about the NADC Bursary (check more than one if applicable):

□ NADC website Q Family Q School / College counsellor at _____________

□ ALIS website □ Friends □ NADC Awards Bursaries Scholarships Booklet
U Flyer U Career Fair a t_______________________ L_) O th e r____________________

Have you answered ALL the questions?

Page 3 of 4
Page 120
Section 9 D E C L A R A TIO N O F A P P L IC A N T

I declare that:
♦ the information given on this application is true and complete and I understand it is subject to audit.
I agree to:
♦ immediately notify Alberta Innovation and Advanced Education in writing if I change my educational institution,
program or study period;
♦ provide information or documents as requested by Alberta Innovation and Advanced Education to verify any
statement made in this application; and
♦ the release and exchange of personal banking information including my bank account number by and between
Alberta Innovation and Advanced Education and lending institutions for the purposes of direct deposit of funds as
determined by Alberta Innovation and Advanced Education.
I understand that:
♦ I may have to immediately repay my bursary if there are changes to my educational institution, program or
study period, or I do not fulfill my return service requirement;
♦ if I make a false or misleading statement in this application or fail to disclose information as requested by Alberta
Innovation and Advanced Education, I may be denied financial assistance and/or required to immediately repay all
financial assistance received;
♦ Alberta Innovation and Advanced Education is not responsible for securing my employment after I have completed
my course of study.
I consent to:
♦ information from my student loan application and assessment to be used for verifying my financial need for this
bursary;
♦ the disclosure and exchange of personal information and documents by and between Alberta Innovation and
Advanced Education and post-secondary institutions and any third party authorized to collect a debt owed to the
Crown;
♦ the Northern Alberta Development Council (NADC) accessing this application and releasing information contained
herein to employers and other government agencies for consideration under the Bursary Partnerships Program or
to employers interested in hiring bursary recipients;
♦ the release and exchange of this information by and between the NADC, the Federal Government and Alberta
Innovation and Advanced Education for the purposes of statistical analysis and program evaluation;
♦ NADC contacting and obtaining information from future employer(s) to verify employment data as required under
the conditions of the bursary contract; and
♦ the public release of my city/town, residency and educational information if I receive the NADC Bursary.

S ig n a tu re (in ink) Todc j y ’s D ate (ir ink)

dc>y mo nth Year

A p p lic a tio n s ca n be a c c e s s e d o n -lin e b u t m u s t be p rin te d , s ig n e d , a n d o rig in a l s e n t to th e s p o n s o r

A p p lic a tio n s m u s t be s e n t b y th e s p o n s o r to th e N A D C b y N o v e m b e r 30th, o f th e a c a d e m ic y e a r fo r w h ic h th e

b u rs a ry is a w a rd e d .

STUDENT SPONSOR
Did you: Send student's o rig in a l application and
□ complete all the application questions? ‘S p o n s o r R e q u e s t fo r M a tc h in g F u n d s ’
form to:
□ sign and date the application?

Send your o rig in a l application to your N o rth e rn A lb e rta D e v e lo p m e n t C o u n c il

P o s ta l B ag 9 0 0 - 14
Bursary Partnerships Program
P eace R iv e r, A B T8S 1T4
sponsor.
Do n o t mail to NADC. (780) 624-6545 (to ll fre e f ir s t d ia l 310-0000)

Visit www.benorth.ca for applications and bursary information

Page 4 o f 4
Page 121
 Ml1

■tk.

r7 I

Student Aid Alberta

Aboriginal Health
Careers Bursary

Page 122
 Aboriginal Health Careers Bursary
In 1995, Alberta Health and Wellness created the Aboriginal Health Strategy with the long-term goal of reducing the inequalities in health
status between Aboriginal and non-Aboriginal people of Alberta.

Part of this strategy included the creation of the Aboriginal Health Careers Bursary, to assist aboriginal students taking post-secondary
education in a health field. The award was established through the Alberta Heritage Scholarship Fund Endowment Program.

Award Value- $2,000 to $11,000

Eligibility Criteria
Applicants must be:
• First Nations, Inuit, or Metis students,
• an Alberta resident and to be considred an Alberta resident one of the following conditions must apply:
*one parent must currently be residing in Alberta, or Alberta is the last place you have lived for twelve (12)
consecutive months before being a full-time student, or
*you are marrried to an Alberta resident before the start of your qualifying year of study, and
• enrolled or planning to enroll full-time in a health related field at the post-secondary level.

Selection Procedure
Recipients will be selected by a selection committee, and priority will the given in the following order of importance:
• involvement in the aboriginal community,
• the applicant’s health career goals, particularly how they will help meet the current and future health care
needs of Alberta’s aboriginal population.
• previous academic record,
• financial need, and
• experience in the health care field.

Application Procedures
The application form is available on the Student Aid Alberta website. Applicants must mail in application forms with the following
attachments, unstapled (photocopy/faxes/scans are not accepted):

• proof of aboriginal status,

• an original post-secondary transcript,
• a career essay, and
• one letter of support from your aboriginal community.

Students must mail their applications to: Student Aid Alberta

PO Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Incomplete applications will not be submitted to the committee. Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Applicants will be notified of the status of their application in July. Recipients may expect to receive their award in November.

Application Deadline: May 1

Page 123
 ABORIGINAL HEALTH CAREERS BURSARY

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
Alberta Student Number (go to ed u c a tio n .g o v .a b .ca . to find your ASN or to obtain one) Social Insurance Number (required for processing)

First Name and One Initial (current full legal nam e)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birtl Email

J ____ I____ L
day month year

CITIZENSHIP (check one)

CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card Visa students arc not eligible.
ALBERTA RESIDENCY

month year

PROPOSED POST-SECONDARY STUDIES

Name of Institution Name of Program

Location (If outside Alberta, please provide com plete address.) Length of Program Year of Program

Number of years
□1st □2nd □3rd □4th
Academic Year Begins Academic Year Ends
_L J ____ I____ L J ____ I____ L
month year month year

Please indicate your aboriginal status: Treaty, Non-Status, C31, Metis or Inuit
Attach a copy of your aboriginal status.

Office Use Only

51 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Disbursement

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: Jan. 2016

Page 124
 Education Record
Please list the last three schools, colleges or universities that you attended. If you have attended more
than three educational institutions you may include the information on a separate page.

PERIOD OF STUDY INSTITUTION

F r o m (m m /y y ) T o ( m m /y y ) N a m e o f I n s t it u t io n Program

Financial Information
Marital Status: Married___ Single ____ Single Parent ___ Number of dependents living with you:

MONTHLY EXPENSES (while in school) MONTHLY INCOME (income while in school)

Rent/Mortgage payment Wages/Salary after deductions

Utilities (power, water, telephone, heating) Spousal/Partner income after deductions

Food/Clothing/Personal Care Contribution from parents

Transportation Child Support/alimony

Child care/Babysitting *Government Funding: indicate source:

Additional expenses (i.e. medical)
Other Income (indicate source)
List

Total Monthly Expenses Total Monthly Income

Total Monthly Income X number

Total Monthly Expenses X number of months in school (D)
of months in school (A)

EDUCATION EXPENSES ( I n c lu d e i f n o t c o v e r e d b y s p o n s o r s h ip )

Tuition OTHER RESOURCES

Fees Savings when you start school

Books/Supplies/lnstruments Other funding ie. grants, scholarships

(excluding loans and lines of credit)
Total Educational Expenses (B) List:

Total Other Resources (E)

Add together monthly and educational
expenses (A + B) = (C) Add together monthly and Other
Resources (D + E) = (F)
ASSETS Value
Calculated Need:
Registered Retirement Savings Plan Total Expenses (C)____________
Assets (i.e. term deposits, bonds, stocks) Minus Total Resources (F )___________ = Total Need____________
•jf
Total Assets If you are not receiving funding from your band or other aboriginal
association or group, please provide a comment in your essay.
Page 125
 Aboriginal Involvement
Selection o f recipients is dependent upon a number of factors such as: involvement in the aboriginal community,
health career goals and employment prospects, academic record and financial need. The selection committee would
like to stress that involvement and commitment to your aboriginal communtiy plays a significant role in determining
the amount of the bursary.

Essay Question

In one or two TYPED pages, please address the following points:

* Provide a brief history o f your experience within aboriginal communities and describe your current
involvement in your aboriginal community i.e. volunteer work, employment, etc.,
* Describe in detail, your health career goals and why you chose to pursue this field,
* Explain how your future employment will help and/or support your aboriginal community after graduation,
* Comment on your experience in this area and health care in general,
* Provide a brief explanation o f your financial need such as: if you are not receiving funding from your
band or other aboriginal association or group, please explain why; if you lack personal resources such as
no savings/income from partner (married or living common-law) explain why; if not applying for
government student loans and grants, explain why.

This is your opportunity to demonstrate to the committee that your commitment to your aboriginal community,
your current study plans, and previous experience will help meet the current and future health care needs of
Alberta’s aboriginal population.

Reference

One reference is required and it must be current, dated and signed and submitted on letterhead.
If the reference is missing, your application will not be submitted to the committee for consideration.

An Aboriginal letter of support is essential: This letter must be from a member of your aboriginal community
and should provide some background on your involvement in the aboriginal community and the appropriateness
o f your training. Please indicate the name o f the individual, position and/or title, who will be providing this
letter.

Name o f individual providing the reference:

Name o f Individual Position and/or Title

Declaration must be signed on the next page.

Ensure all questions are answered.

Your application will be delayed if information is missing.

Page 126
 Declaration of Applicant
I have read and understand the instructions, and declare that:
a. all information provided is true and complete and I understand it is subject to verification;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic record and enrolment status may
be released and exchanged by and between Student Aid Alberta and the educational institution for the
purpose of determining my eligibility for a scholarship;
b. my personal information may be released and exchanged by and between Student Aid Alberta and any
provincial government departments, boards or institutions to verify the information 1 have provided to
Student Aid Alberta, and for the use in research and statistical analysis in program evaluation.

I understand and agree that:

if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if 1 do not want to be identified, I will
contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

A p p lic a n t’s C h e c klis t

Proof of aboriginal status

An original transcript

A typed health career essay

1__ I Letter of reference from Aboriginal community.

A pplications m ust be postm arked no later than May 1. Notification of results can be expected in July.

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship
Fund is designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and
assisting Albertans to achieve the fullest potential.

Further information on other awards is available on: studentaid.alberta.ca/scholarships

Page 127
 Student Aid Alberta

Language Bursary Program for

Teaching FNMI Languages

Page 128
 Language Bursary Program for Teaching FNMI Languages
The Language Teacher Bursary program was created by an endowment to the Alberta Heritage Scholarship Fund as part of the
government of Alberta’s Economic Development Strategy. It was established so teachers may improve their language fluency,
pedagogical skills and knowledge through an educational immersion experience, and to help Alberta jurisdictions enhance their
current language teaching capacity.
Up to two bursaries of $2,500 for study in Canada.
The program will assist Alberta teachers, Elders or instructors currently providing instruction of an FNMI language and intend to take
a summer post-secondary program. Students will benefit from the enhanced teaching and language skills of their teachers,
encouraging them to take up the challenge of learning an FNMI language and culture and to assist with the FNMI language
revitalization and/or renewal.
Post-secondary students in a recognized teacher preparation program in Alberta should contact Student Aid Alberta about
the Languages in Teacher Education Scholarship.

Eligibility Criteria
Applicants must:
• be a Canadian Citizen or Permanent Resident, and be an Alberta resident,
• either be working towards Alberta certification or hold a valid Alberta professional teaching certificate;
• have been teaching in Alberta for a minimum of one year by the end of the current school year;
• demonstrate a background in FNMI language learning and culture, or have recently initiated the study of an FNMI language;
• plan to take a summer program of at least three weeks duration in an indigenous language teaching methodology.
Note: Priority is given to first time applicants, however, previous recipients of three or more years ago may re-apply.

Program Eligibility Criteria

The summer language development program must be:
• a university credit course focusing on language, culture and/or pedagogical development, e.g. CILLDI
• a minimum of three weeks in duration, and
• a minimum of three hours daily scheduled classroom instruction, with an expectation of additional scheduled, structured
activities (e.g. language conversation, tutorials, cultural activities).

Selection Procedure
Bursary recipients will be chosen by a selection committee with decisions based on the applicant's statement of program, school, and
school authority endorsement. The selection committee bases its decisions on information submitted with the application and any
changes may jeopardize the receipt of payment of the bursary.

Application Procedure
Include with your application a copy of your resume. Submit the completed application package (application form and supporting
documents) to your school jurisdiction (superintendent or designate), or First Nations Education Authority for endorsement.
Once endorsement has been given, the school jurisdiction or the First Nations Education Authority will forward your application to
Student Aid Alberta for consideration.

Applicants are reminded to meet their school jurisdiction’s procedures and deadlines. The school authority must mail its endorsement,
along with the application package to Student Aid Alberta by February 10.

Submit your completed application to your school jurisdiction (superintendent or designate) or

First Nations Education Authority for endorsement.

The school authority will then submit your application to Student Aid Alberta by February 10.

Page 129
 Language Bursary Program for Teaching FNMI Languages

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the Alberta
Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information, please
contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
AB Professional Teaching C ert. No. (if applicable) * A lberta S tudent N u m b e r (ASN) S ocial In s u ra n c e N u m b e r

Last Name (full legal name) First Name and One Initial (full legal name)

City/Town

*You may use the Learner Registry at

www.education.gov.ab.ca to Find your ASN
Province Postal Code Area Code Telephone Number or to have one assigned.

CITIZENSHIP (check one) Number of Years of Teaching or Instructing in Alberta:

CANADIAN CITIZEN OR Full-time ---------- Part-time----------

PERMANENT RESIDENT

Recipients will receive their bursary after submitting proof of completing their course.
Scholarships, fellowships and bursaries are tax exempt, however, please contact the Canada Revenue Agency for details
on the reporting requirements and tax treatment of income from these sources.

Office Use Only

Revised: Jan. 2016

Page 130
 Proposed Studies

Program Name__________________________________________________ Language of Study

Commencement Date (Day/M onth/Year) Completion Date (Day/M onth/Year)

I I I I Proposed Studies:
---- 1----- 1----- 1----- 1-----1----- 1----- 1----- ----- 1----- 1----- 1----- 1-----1----- 1----- 1----- No. of Days per week___ No of Weeks____
No. of Hours of instruction per day: ___
Focus of Studies:
---------------------------------------------------------------------------------------------------------- Improving language fluency:
___Oral ___ Written
Address of institution offering program Gaining cultural knowledge___
Enhancing pedagogy ___
Working towards completion of teacher certification.

Elaborate on the focus of the course. For example, how does this course develop or enhance your knowledge of your language
and culture and/or your teaching skills:______________________________________________________________________

Estimated Expenses
Have you applied or will you be applying for funding from another source, c.g. First Nations Education Authority
(FNEA), to participate in this program?
YES ---------N O ----------
If “YES”, please indicate the source of funding and amount of support:_________________________________

Do you anticipate receiving funding from another source, e.g. FNEA, to participate in this program?
YES --------- NO --------
If “YES” please indicate the source and amount of support:________________________________

Page 131
 Please attach a resume including your education and work history.

Language Teaching/lnstructional Experience:

Please provide a summary of FNMI languages and grade level you have taught, or current role in FNMI languages at your school:

Check all boxes that apply to you:

Cl A language and culture expert □ A fluent speaker □ New to learning this language
□ New to language teaching □ Returning to teach a language after some time
□ Elder Indicate your assignment in the next school year:
□ Currently teaching this language

Language Background: What is the language you are most proficient in?_____________________
Indicate proficiency in FNMI language: Excellent, Good, Fair, Needs improvement
Reading:
Writing:
Speaking:
Cultural Knowledge:

Supporting Documents
Statement of Intent:
Attach a statement (one page maximum) explaining your reasons for taking the program.
1. How will this particular program:
• benefit your current/future employment as an FNMI language teacher in Alberta?
• fit into your professional development/growth plan?
2. How will this bursary impact your role in the FNMI languages program?
3. How do you plan to share this knowledge with colleagues?

Professional Development Summary:

Attach a brief summary outlining relevant professional development. Be sure to outline your recent efforts to enhance
and/or develop:
1. Language and culture
2. Teaching and/or leadership skills in the area of language teaching

Course Syllabus:.
Attach brochure or syllabus describing the focus of the course, its duration and intensity.

Page 132
 Declaration of Applicant

I HAVE READ THE INSTRUCTIONS, AND DECLARE THAT:

(a) I have answered all questions applicable to me and that all information is true and complete;
(b) I propose to take the course named for the period stated;
(c) I will notify Student Aid Alberta should I withdraw from studies;
(d) I agree to allow my name, city/town, program information, school, and jurisdiction to be released to the
media and appropriate Members of the Legislative Assembly (MLAs) if I receive this award; and,
(e) I authorize the release and exchange of personal information by and between Student Aid Alberta and
Alberta Education and any federal and provincial government departments, boards or institutions to verify the
information I have provided to Student Aid Alberta and for the use in research and statistical analysis
in program evaluation and program promotion.

Signature of Applicant (in ink) Today’s Date (in ink)

Applicant Checklist

My application is complete in its entirety and the following documents are attached:

□ Statement of Intent
□ Program Brochure or Syllabus
□ Professional Development Summary
□ Resume
I I Application is signed, dated and completed in ink.

I I Entire application package including your current supervising administrator’s endorsement (School Principal
Part 1) is forwarded to your local school jurisdiction or First Nations Education Authority for review.

Notes to Applicant

Submit your completed application package to your school jurisdiction or First Nations of
Education Authority. Please allow sufficient time to the local school authority to complete their
endorsement in order to meet the February 10 application deadline.

Incomplete applications are not considered. Do not submit your application to Student Aid Alberta.

Page 133
 School Endorsement - Part 1
To be Completed by Applicant’s Current School Principal
N o t e : T h e S election C o m m itte e n e ed s c le a r a n d concise in fo rm a tio n on y o u r F N M I la n g u a g e p ro g ra m n eed s a t y o u r school a n d how it is
e x p ec te d th e a p p lic a n t’s s u m m e r p r o g r a m w ill b e n e fit th e sch o o l a n d m ee t th e sc h o o l’s F N M I la n g u a g e needs.

Name of Applicant: _______________________________________________

What is the anticipated assignment of this applicant in the 2015/2016 school year? (courses, grade, etc.)

Will this applicant be (check all appropriate boxes):

____ returning to the same school?
____ at another school? ___________________
____ taking on a new assignment?
___ returning to the same assignment?
____ unsure at this time
___ other_______________________________

How long has this applicant been under your supervision? _____________________________

What language programs/projects/initiatives has this applicant led or assisted with while under your supervision?

This school needs FNMI (check the most appropriate): This applicant is (checke one):
a lead/master teacher in FNMI language & culture ____ a lead/master teacher in the chosen language
____ this teacher to refresh/enhance skills ____ a teacher returning to teaching languages
___ this instructor to obtain teaching credentials ____ new to teaching this language
____ an Elder community member who wishes to complete a
teacher prepation program
____ new to language learning

How will students in your school benefit from the applicant’s experienee?

How will this summer language program fit into this teacher’s professional development?

How will this applicant’s participation fit into your school’s FNM language plan?

Name of Principal (please print) Signature (in ink) Today’s Date

Name of School: School Location:

School Authority Contact: _______________________________________________ Telephone:

Application Deadline: February 10

Page 134
 School Authority Endorsement - Part 2
To be Completed by the School Jurisdiction (Superintendent or designate) or First Nations
Education Authority

N o te: T h e S electio n C o m m itte e n e e d s d e a r a n d con cise in fo rm a tio n on y o u F N M I la n g u a g e p ro g ra m n e ed s in y o u r school d ivision

a n d ho w i t ’s e x p ec te d th e a p p lic a n t’s s u m m e r p r o g r a m w ill b e n efit th e school a n d m ee t th e school d iv is io n ’s F N M I la n g u a g e needs.

NAME OF APPLICANT: ___________________________________________

This applicant’s participation in the described language program will support the school authority’s language plan by (check
appropriate statement(s):
___ enhancing the language expertise already available in the district
___ beginning to develop district expertise in this language
___ providing much needed leadership to this school
___ meeting a staffing need through in-service development of this teacher’s language skills
___ beginning the journey of developing language programming

How will the experience and skills acquired by this applicant participating in this particular program benefit the school and school
authority?

It is important for the selection committee to know about:

- this applicant
- the language staff needs of this school
- other key consideration
- expected assignment in the next school year

Name (please print) Signature (in ink) Today’s Date

Position School Authority Name Phone Number

School authority must mail an endorsement of the applicant and application package to Student Aid Alberta by February 10.
Faxed applications are not accepted.

Mail to: Student Aid Alberta

Box 28000 Station Main
Edmonton, Alberta T5J 4R4

For information on this award and other scholarships:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Page 135
' *
Student Aid Alberta

Language Teacher
Bursary Program

Page 136
 Language Teacher Bursary Program
The Language Teacher Bursary program was created by an endowment to the Alberta Heritage Scholarship Fund as part of the
Government of Alberta’s Economic Development Strategy. It was established so teachers may improve their language fluency,
pedagogical skills and knowledge through an educational immersion experience, and to help Alberta jurisdictions enhance their
current language teaching capacity.
Approximately ten bursaries of $5,000 each for study outside of Canada.

The program will assist certificated Alberta teachers to take a summer post-secondary program in a language other than
English or language pedagogy course at an institution outside of Canada. Teachers of Aboriginal languages, whose language of
study is only available in Canada, are eligible. Students will benefit from the enhanced pedagogical and language skills of their
teachers, encouraging them to take up the challenge of learning a new language making them more globally competitive.
Post-secondary students in a recognized teacher preparation program in Alberta should contact Student Aid Alberta
about the Languages in Teacher Education Scholarship.

Teacher Eligibility Criteria

Applicants must:
• be a Canadian Citizen or a Permanent Resident, and be an Alberta resident,
• hold a valid Alberta professional teaching certificate,
• have been teaching in Alberta for a minimum of three years (FTE) by the end of the current school year,
• demonstrate a background in language learning, or have recently initiated the study of this language, and
• plan to take a summer program of at least four weeks duration in a language and/or language teaching methodology other
than English outside of Canada.
Note: Priority will be given to first time applicants, however, recipients who received a bursary five years ago or earlier can
re-apply.

Program Eligibility Criteria

The summer language development program must be:
• a minimum of four weeks in duration;
• a minimum of three hours daily scheduled classroom instruction, with an expectation of additional scheduled, structured
activities (e.g. language conversation, tutorials, cultural activities);
• a university credit course, or a language/culture/pedagogical development program, in a language other than English that
is offered by a post-secondary institution, or an organization recognized by the local government (e.g. Goethe Institute,
Cervantes Institute) outside of Canada.

Selection Procedure
Recipients will be chosen by a selection committee with decisions based on the applicant's statement of program, course rigour,
school authority endorsement, and the potential benefit for both the teacher and the school authority. The selection committee
bases its decisions on information submitted with the application and any changes may jeopardize the receipt of payment of the
bursary. Every effort will be made to represent various grade levels and languages from across Alberta.

Application Procedure
Include with your application a copy of your resume. Submit the completed application package (application form and
supporting documents) to your school authority office for endorsement. Once endorsement has been given, the school authority
will forward your application to Student Aid Alberta for consideration. School Authorities must mail applications to
Student Aid Alberta by February 10. Submit your application early to your School Authority to allow sufficient time to
meet the February 10 submission deadline.

Submit your completed application to your School Authority.

School Authorities must submit applications to Student Aid Alberta by February 10.

Page 137
 Language Teacher Bursary Program

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the Alberta
Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information, please
contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
A lb erta Professional Teaching C ertificate N u m b e r *A lb erta S tudent N u m b e r (ASN) S ocial In s u ra n c e N u m b e r

Last Name (full legal name) First Name and One Initial (full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

*You may use the Learner Registry at

cducation.gov.ab.ca to find your ASN or to
Province Postal Code Area Code Telephone Number have one assigned.

CITIZENSHIP (check one) NUMBER OF YEARS TEACHING

C a n a d ia n c it iz e n or In Alberta** Full-time _______ Part-time__

D ERMANENT RESIDENT Outside Alberta Full-time _______ Part-time_______

Location:
Gender (circle one) Birthdate (Day, M onth, Year)
M F **Minimum of three years (FTE) of teaching in Alberta is required.
___I___ ___ I___I___I___ I___ I___

Email address:

Name of university you received your teaching degree: Year of completion:

Recipients will receive their bursary after submitting proof of completing their course.
Scholarships, fellowships and bursaries are usually tax exempt, however, please contact the Canada Revenue Agency for details on
the reporting requirements and tax treatment of income from these sources.

Office Use Only

Revised: Jan. 2016

Page 138
 Proposed Studies

NOTE: Receipt of a bursary does not imply recognition of the course by Teacher Qualifications Service

Program Name

Commencement Date (Day/M onih/Year) Completion Date (Day/Month/Year)

J ____ L J ____ L
Name of institution offering program Proposed Studies:
No. of Days per week___ No of Weeks
No. of Hours of instruction per day: ___
Address of institution offering program Focus of Studies:
Improving language fluency:
___ Oral ___ Written
Gaining cultural knowledge___
Enhancing pedagogy ___

Elaborate on the focus of the course such as how this course will develop your language and/or pedagogical skills and
enhance your knowledge of the culture. Please include a program brochure or course syllabus (in English).

Estimated Expenses

1. Tuition Include a separate sheet to explain any exceptional or unusual expenses

2. Travel or other financial conditions that you would like to bring to the
3. Accommodation committee’s attention.

4. Meals
Total All dollar amounts should be in Canadian funds.

Are you applying for funding from another source to participate in this program?
YES EH NO EH
If “YES” please indicate amount:
and type of support e.g. in-country accommodation:

Do you anticipate receiving funding from another source to participate in this program? 1 I YES I I NO

If “YES” please indicate amount:

Page 139
 Please attach a resume including your education and work history.

Language Teaching Experience: List all language courses and grade level you have taught in the last five years
beginning with your current teaching assignment:

Courses/Grade Level Description School Year

Language Learning: List your formal language learning i.c. language courses, program, dcgrcc(s) completed, etc.:

Courses/Program Offered by: Year

Check all boxes that apply to you:

D New to second language teaching D Returning to teach a language after some time O Currently teaching this language
New to learning this language** Q A fluent speaker Q A language expert (language
*must have begun study of this language in Alberta lead/master teacher)
Language Background: What is the language you are most proficient in?
Indicate level of proficiency in all languages other than English: Excellent, Good, Fair, Needs improvement:
L anguages:
Reading:
Writing:
Speaking

Additional Supporting Documents

Q Statement of Intent:
Attach a statement (one page maximum) explaining your reasons for taking the program.
1. How will this particular program:
• benefit your current/future employment as a language teacher in Alberta?
• fit into your professional development/growth plan?
• if not currently teaching a language other than English, indicate when you would be ready to teach the
language you will be studying.
2. How you plan to share this knowledge with colleagues?

O Professional Development Summary:

Attach a brief summary outlining all relevant professional development you have completed in the last five years.
Ensure to outline your recent efforts to enhance/develop:
1. Skills in this language
2. Pedagogical and/or leadership skills in the area of language teaching

0 Course Syllabus:.
Attach brochure or syllabus, in English, describing the focus of the course; its duration and intensity.

Page 140
 Declaration of Applicant

I have read and understand the instructions, and declare that:

(a) I have answered all questions applicable to me and that all information is true and complete;
(b) I propose to take the course named for the period stated;
(c) I will notify Student Aid Alberta should I withdraw from studies;
(d) I agree to allow my name, city/town, program information, school, and jurisdiction to be released to the
media and appropriate Members of the Legislative Assembly (MLAs) if I receive this award; and,
(e) I authorize the release and exchange of personal information by and between Student Aid Alberta and
Alberta Education and any federal and provincial government departments, boards or institutions to verify
the information I have provided to Student Aid Alberta and for the use in research and statistical analysis in
program evaluation and program promotion.

Signature of Applicant (in ink) Today’s Date (in ink)

Applicant Checklist
Application is completed in its entirety and the following documents are attached:

□ Statement of Intent
□ Program Brochure or Syllabus (in English)
□ Professional Development Summary
□ Resume

I I Application is signed and dated in ink.

] Entire application package including your current supervising administrator’s endorsement (School Authority
Endorsement - Part 1) is forwarded to your local school authority contact* for review.

Notes to Applicant
Do not submit your application to Student Aid Alberta:

Submit your completed application to your local school authority. The local school authority will
mail your application package to Student Aid Alberta. Please allow sufficient time for your local
school authority to complete their endorsement in order to meet the February 10 application
deadline. Incomplete applications are not considered.

Contacts for Metro Boards:

Calgary Board of Education: Director, Global Learning Services

Calgary Catholic School District: Mr. Helmut Kaiser, Supervisor, French and International Languages
Edmonton Public Schools: Ms. Renee Thomson, Manager, Staff Development, Human Resources Consulting
Edmonton Catholic Schools: Marc Motut, Staffing, Human Resources Services

Page 141
 School Authority Endorsement - Part 1
To be Completed by Applicant’s Current Supervising Administrator

N ote: T h e S electio n C o m m itte e n e ed s c le a r a n d concise in fo rm a tio n on y o u r lan g u a g e p ro g ra m n e ed s a t y o u r school a n d ho w it is e x p ec te d

th e a p p lic a n t’s s u m m e r p ro g ra m w ill b e n e fit th e school a n d m ee t th e sc h o o l's la n g u a g e needs.

Name o f Applicant: ____________________________________________________

What is the anticipated assignment of this applicant in the 2014/2015 school year? (courses, grade, etc.)

Will the applicant be teaching a language other than English? If so, please indicate what language ____________________
if not teaching a language other than English, how will the applicant’s participation benefit your school and the school division?

The applicant will be:

____ returning to the same school teaching at another school_____
____ taking on a new assignment returning to the same assignment
___ unsure at this time other

How long has this applicant been under your supervision? _____________________________

What language programs/projects/initiatives has this applicant led or assisted with while under your supervision?

This school needs (check the most appropriate): This applicant is (check one):

____ a lead/master teacher in this language a lead/master teacher in the chosen language
___ this teacher to refresh/enhance skills a teacher returning to teaching languages
___ a teacher for this second language _ new to teaching this language
_ new to language learning

How will students in your school benefit from the applicant’s experience?

How will this summer language program fit into this teacher’s professional development plan and how will it fit into your school’s
language plan?

Name & Position (please print) Signature (in ink) Today’s Date

Name of School:___________________________________ School Location: ______________________________

Name of Principal: _______________________________________________ Phone Number: __________________

Application Deadline: February 10

Page 142
 School Authority Endorsement - Part 2
To be Completed by Applicant’s Superintendent or School Jurisdiction Key Contact

N ote: T h e S electio n C o m m itte e n e ed s c le a r a n d c o n cise in fo rm a tio n on th e la n g u a g e p ro g ra m n e ed s in y o u r school d ivision a n d ho w it is

e x p ec te d th e a p p lic a n t's s u m m e r p ro g ra m w ill b e n e fit th e school a n d m e e t th e school d iv is io n ’s la n g u a g e needs.

Name of Applicant: ___________________________________________

This applicant’s participation in the described language program will support the school authority’s language plan by (check
appropriate statement(s) - attache additional inforamtion as needed:
____ enhancing the language expertise already available in the district
____ beginning to develop district expertise in this language
____ providing much needed leadership to this school
____ meeting a staffing need through in-service development of this teacher’s language skills
____ beginning the journey of developing language programming

How will the experience and skills acquired by this applicant participating in this particular program benefit the school and school
authority?

What is important for the selection committee to know about:

- this applicant?
- the language staff needs of this school?
- the language program needs for your school authority/division/district?
- other key consideration?

Name (please print) Signature (in ink) Today’s Date

Position School Authority Name Phone Number

School authority must mail an endorsement of the applicant and application package to Student Aid Alberta by February 10.
Faxed applications are not accepted.

Mail to: Student Aid Alberta

Box 28000 Station Main
Edmonton, Alberta T5J 4R4

For information on this award and other scholarships:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Page 143
Carmangay Home <&
School Association
Scholarship

Page 144
 Carmangay Home & School Association Scholarship
The Carmangay Home & School Association Scholarship was created in 2001 to recognize the accomplishments of students who
attended Carmangay School and to commemorate the closing of the school.

An endowment was established by the Carmangay Home & School Association to offer a yearly scholarship until 2013.

Award Value - $2,500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Pennanent Resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have attended Carmangay School for at least one complete school year,
c. have achieved a high academic standing in their Grade 12 year at an Alberta high school,
d. plan to enroll or be enrolled full-time in a post-secondary program, and
d. demonstrate outstanding qualities in the areas of leadership, community spirit, and involvement in extra-curricular
activities.

Selection Procedure
The selection committee will select recipients on the basis of academic achievement and demonstrated leadership skills, community
involvement, and participation in extra-curricula activites.

Application Procedure*

Submit to Alberta Scholarship Programs:

* completed application form,
* a summary of your leadership activities, community involvement, and extra-curricular activities, and
* proof of attendance at Cannangay School

Students will be notified of the status of their application in October and the award is issued in November after Alberta Scholarship
Programs confirms full-time enrolment.
Mail to: Courier to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline: August 1

 Carmangay Home and School Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) (L’ity/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M d^iy | rmyilh | | ye;jr |

CITIZENSHIP (check one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
__ I______ I___I___I__
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Did you attend Carmangay School? | | Yes, what year__________| | No

Include proof that you have attended Carmangay School.

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month | year month I year
____i____ ____ i__ _ i____ i____
Institution City Length of Program Year of Program
□ 2nd 3rd 4th

Office Use Only

77 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Disbursement

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: March 2013

Page 146
 In two pages or less, please include a summary of your leadership activities,
volunteer involvement both in your school and in your community, and
extra-curricular activities. Please state the time commitment for each
activity, e.g. one hour, one day, one month, one year, etc.

Declaration of Applicant
1 HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by
and between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility
for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any
provincial government departments, boards or institutions to verify the information I have provided to Alberta
Scholarship Programs and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships
 S tu d e n t A id A lb e rta Consent and Declaration Form

PO Box 28000, Station Main

Edmonton, Alberta
T5J 4R4

Notice to the Applicant: If you are married/common law, your spouse/partner will need to sign below. This form must be signed and received
by Student Aid Alberta at least 30 days before your program end date. Otherwise, your funding may be cancelled. Once signed, return to
Student Aid Alberta, PO Box 28000, Station Main, Edmonton AB T5J 4R4.

Collection, Use and Disclosure of Spouse/Partner Information

The Applicant has applied online for student
aid. If you are the spouse/partner of the
Applicant, the Application included your name,
social insurance number, birth date, date you
last attended high school, Alberta residency
information, employment status, income, and
whether you will be a full-time student during
the Applicant’s study period.
Innovation and Advanced Education is
collecting the personal information in the
Application and this Consent and Declaration
to determine and verify the Applicant’s eligibility
for financial assistance, to administer (including
research, statistical analysis, and evaluations)
and to enforce student financial assistance
programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada
Student Loans Act and the Canada Student
Financial Assistance Act. The collection of
your personal information is done under
the authority of sections 33(a), 33(c), and
34(1 )(a)(i) and (ii) of the Alberta Freedom of
Information and Protection of Privacy Act
(FOIP) and section 14.1 of the Student Financial
Assistance Regulation (Alberta) and is managed
in accordance with FOIP.
The personal information in the Application
for financial assistance and any applicable
Schedules may be disclosed to:
• federal, provincial or territorial government
departments or agencies to verify any
information the Applicant provided,
determine the eligibility of the Applicant
for financial assistance and to administer
student financial assistance programs.
• the federal government for use in research,
statistical analysis and evaluations related to
student financial assistance programs.
• Alberta Fluman Services to operate and
administer provincial and federal student
financial assistance programs, including your
eligibility, and the eligibility of the Applicant,
for financial assistance.
• any municipal government department or
agency, landlord, lending institution, credit
bureau or employer to verify any information
the Applicant provided, to determine the
eligibility of the Applicant for financial
assistance and to administer student
financial assistance programs.
If you have any questions about the collection,
use or disclosure of this information, call
the Student Aid Alberta Service Centre
at 1-855-606-2096. You can also mail
your questions to Student Aid Alberta,
Privacy Officer, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.

Canada Revenue Agency Consent

I hereby consent to the release, by Canada Revenue Agency to an official of Innovation and Advanced Education, of information from my income tax
returns and, if applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant to
and used solely for the purpose of determining and verifying the Applicant’s eligibility, entitlement for and the general administration and enforcement
of the student financial assistance programs under the Canada Student Loans Act, the Canada Student Financial Assistance Act, the Students Finance
Act (Alberta), the Student Loan Act (Alberta) and the Student Financial Assistance Act (Alberta). This authorization is valid for the taxation year prior to
the year of signature of this consent, the year of signature of this consent and any other subsequent taxation year for which assistance is requested by
the Applicant.

Spouse/Partner {in ink) Social Insurance Number (in ink)

Signature of Spouse/Partner (in in k ) Today’s Date (in in k )

Day Month Year

X
I , I I I

Page 148
 S tu d e n t A id A lb e rta Consent and Declaration Form

PO Box 28000, Station Main

Edmonton, Alberta
T5J 4R4

Notice to the Applicant: If you are married/common law, your spouse/partner will need to sign below. This form must be signed and received
by Student Aid Alberta at least 30 days before your program end date. Otherwise, your funding may be cancelled.

Collection, Use and Disclosure of Spouse/Partner Information

The Applicant has applied online for student
aid. If you are the spouse/partner of the
Applicant, the Application included your name,
social insurance number, birth date, date you
last attended high school, Alberta residency
information, employment status, income, and
whether you will be a full-time student during
the Applicant’s study period.
Innovation and Advanced Education is
collecting the personal information in the
Application and this Consent and Declaration
to determine and verify the Applicant’s eligibility
for financial assistance, to administer (including
research, statistical analysis, and evaluations)
and to enforce student financial assistance
programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada
Student Loans Act and the Canada Student
Financial Assistance Act. The collection of
your personal information is done under
the authority of sections 33(a), 33(c), and
34(1 )(a)(i) and (ii) of the Alberta Freedom of
Information and Protection of Privacy Act
(FOIP) and section 14.1 of the Student Financial
Assistance Regulation (Alberta) and is managed
in accordance with FOIP.
The personal information in the Application
for financial assistance and any applicable
Schedules may be disclosed to:
• federal, provincial or territorial government
departments or agencies to verify any
information the Applicant provided,
determine the eligibility of the Applicant
for financial assistance and to administer
student financial assistance programs.
• the federal government for use in research,
statistical analysis and evaluations related to
student financial assistance programs.
• Alberta Fluman Services to operate and
administer provincial and federal student
financial assistance programs, including your
eligibility, and the eligibility of the Applicant,
for financial assistance.
• any municipal government department or
agency, landlord, lending institution, credit
bureau or employer to verify any information
the Applicant provided, to determine the
eligibility of the Applicant for financial
assistance and to administer student
financial assistance programs.
If you have any questions about the collection,
use or disclosure of this information, call
the Student Aid Alberta Service Centre
at 1-855-606-2096. You can also mail
your questions to Student Aid Alberta,
Privacy Officer, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.

Canada Revenue Agency Consent

I hereby consent to the release, by Canada Revenue Agency to an official of Innovation and Advanced Education, of information from my income tax
returns and, if applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant to
and used solely for the purpose of determining and verifying the Applicant’s eligibility, entitlement for and the general administration and enforcement
of the student financial assistance programs under the Canada Student Loans Act, the Canada Student Financial Assistance Act, the Students Finance
Act (Alberta), the Student Loan Act (Alberta) and the Student Financial Assistance Act (Alberta). This authorization is valid for the taxation year prior to
the year of signature of this consent, the year of signature of this consent and any other subsequent taxation year for which assistance is requested by
the Applicant.

Spouse/Partner (in ink) Social Insurance Number (in in k )

Signature of Spouse/Partner (in in k ) Today’s Date (in in k )

Day Month Year

X
_ l | I , I I I

Page 149
 Change of Program Form
for students attending
Student Aid Alberta Private Vocational Schools

Student Information
Student Name: _______________________________________ ASN:
Institution: _________________________________________________
Campus Name: ____________________________________________

Original Program Information

Program Name: _____________________________

Start Date of Original — — — — — — — |— End Date of Original.— — — — — — — —

Program: I I II I I II I Program: I I II I I II I __
Day Month Year Day Month Year

Last day attended Original Program:

Day Month Year

New Program Information

Program Name:

Start Date of New — — — — — 11— -------- End Date of New — — — — — . i— -------

Program: I I II I I II I _ Program: II II
Day Month Year Day Month Year

• If the student’s end date of new program exceeds end date of original program, the student must
submit a new application.
• If there is a break of 30 days or more between study periods, a new application is required.
• Please ensure program dates have been entered onto PAPRS.

Comments

School O fficial Name (Printed) School O fficial Signature

Phone Number Date

Email Address

June 2015
Page 150
 CHANGE REQUEST FORM
R e q u e s te d B y D ate

Processing Changes (See Reverse) I I

CORRESPONDENCE COMMENTS
PER IO D OF S TU D Y

D Institution/Campus Code
From To

□
□ Program Code
From To

□ Commencement Date
From To

Day Month Year Day Month Year

Termination Date
From To

Day Month Year Day Month Year

PROGRAM PAYMENTS & REVENUE SUPPORT

Day Month Year
P ro c e s s R e p a y m e n t: Cheque # Cheque Amt $
Date

Cheque from Letter to student: QYes □ No

Apply $_____ _to Prog Apply $_ to Prog Initials____

C a n ce l F u n d s : Cancel/Reduce Code Withdrawal Date Balance after

r Update:____

Updated: Day Month Year

FORWARD TO • | | Normal Processing | | Update Additional Funds/Stats

Initials:

DISABILITY UNIT
Clay Month Year
Initials: Letter to Student: □ Yes □ No □ NA

C A N C E L L A T IO N / R E D U C TIO N C O D ES

0 Withdrew from Studies 10 60 Day Non Response 19 Cannot Locate Student*

1 Never Attended (Not Accepted) 11 Multiple Application* 20 Change of Program
4 Change of Institution 12 Internal Error* 21 Early Completion
5 Reassessment 13 External Error* 24 Declaration Not Received
6 Not Eligible 14 Deceased* 25 Bankruptcy
9 Replacement 15 Audit-Non/Compliance 27 Not Registered
16 Audit-Reassessment 28 Uncashed Loan Documents(s)
17 Funding Returned 29 Dropped to Part-time Studies
18 Funding Not Reguired 30 MSFAA not approved

*NO NOTIFICATION MAILED TO STUDENT

Change Request Form June 2<^ g e ^

 CHANGE REQUEST FORM
Requested By Date

App ID Award Key

PROCESSING
PERSONAL DATA

□ Marital Status ► FORWARD TO REVIEW UNIT □ Birth Date

From
□ To REVIEWER From To

□ Name ►REQUIRE NAME CHANGE DOCUMENTATION Day Month Year Day Month Year

From
□ Social Insurance Number

To N a m e _________________

From

Reason Code IF REASON CODE IS M, D OR S To

FORWARD TO REVIEW UNIT FIRST

CANCEL / CLOSE APPLICATION

Cancel Reason Code ►s t a t u s c a n n o t be a t c o m p l e t e o r au

CERTIFICATES
| | Replacements

C S L C e rt# r A S L C ert# ► m u s t h a v e o r ig in a l
DOCUMENT OR STATUTORY

□ Special Handling Instructions

DECLARATION ATTACHED

Code

SPECIAL HANDLING
NAME CHANGE CODES
INSTRUCTION CODES
A Return Documents to Requestor L Legal Name Change C Driver’s License
B Return Documents and File to Requestor M Marriage Certificates 1 Immigration Papers
C Courier to School D Divorce Papers K Key Punch Error
D Mail to Student S Separation Papers 0 Other
E Return Documents to Calgary B Birth Certificate E Student Error
F Return Documents and File to Calgary P Passport

Change Request Form June 2014 _

Page 152
 Student Aid Alberta Change of Address
Stay in Touch!

Let S tu d e n t A id A lb e rta k n o w if y o u r c o n ta c t in fo rm a tio n has c h a n g e d .

My personal information:

Last N am e:

F irst N am e:

B irth d a te :

A lb e rta S tu d e n t N u m b e r:

Em ail:

My new contact information is:

A p a rtm e n t/B o x N u m b e r:

S tre e t A d d re s s :

Address Line 1

Address Line 2

C ityA T o w n :____________________________________________________________________

P ro v in c e /S ta te :

C o u n try :

P osta l C o d e:

Em ail:

P hone:

M ail to: S tu d e n t A id A lb e rta , PO B o x 2 8 0 0 0 S tn M ain, E d m o n to n A B T5J 4R 4

Log in to: S tu d e n ts F in a nce S yste m SFS:Login/Apply to u p d a te y o u r p e rson a l in fo rm a tio n .

Page 153
 Page A

Change of Circumstance Form for

Post-Secondary Studies 2014/2015

1. Read the list of changes below and choose only those changes that apply to you. Print the form and complete only the
pages for the changes you require. If you need to submit Schedules 1, 2, 3, or 4, they are posted separately on the web page.
□ Change in Personal Information (legal name, marital status)
□ If your marital status has changed from Single to Married/Common Law, also complete Schedule 2
□ Change in Number of Dependent Children
□ Change in Full-Time or Part-Time Study Information
□ If you are Concurrently Enrolled, also complete Schedule 3 (Concurrently Enrolled
means you are simultaneously attending more than one school on a part-time basis.)
□ Change in Monthly Cost or Resource Information
□ Change in Parental Personal and Financial Information - complete Schedule 1
□ Change in Spouse/Partner Information - complete Schedule 2
□ I am now indicating that I have a Permanent Disability - complete Schedule 4
2. Complete the page with your Personal Information, including your Social Insurance Number, Alberta Student Number, Award
Reference Number, and remember to answer the mandatory Funding Request question.
3. Submit your completed pages to Student Aid Alberta. Remember to include:
• Page A that shows what changes you selected
• the first page with your personal information and mandatory funding request question
• only the pages for each change you require
• acceptable supporting documentation as described on each page

54
 b e r b f iji Change of Circumstance Form for 4/15 C
Student Aid Alberta Post-Secondary Studies 2014/2015
To be completed by applicants who wish to amend information provided in their Application for Financial Assistance.

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and
Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid
Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta,
Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.
Alberta Student Number (mandatory) Award Reference Number
Social Insurance Number (obtained from Alberta High School Transcript) 'Refer to your Notice of Assessment)

__ I__ I I I I__ I__ I__ I__ I__ I__ I I I I I I I I I I __ I__ I__ I__ I__ I__ I__ J__

FUNDING REQUEST (MANDATORY)

Do you require additional funding If yes, how much additional

for your current period of study? Q Yes Q No funding are you requesting? $

APPLICANT DECLARATION

This Change of Circumstance Form for Post-Secondary Studies, including any Schedules and documentation (“Change of
Circumstance Form”), supplements, amends, and forms part of the Application for Financial Assistance that I previously submitted to
the Minister of Innovation and Advanced Education (“Minister”) pursuant to the Student Financial Assistance Act (Alberta), the Canada
Student Loans Act and the Canada Student Financial Assistance Act (“Original Application”).
By submitting this Change of Circumstance Form, I declare that all information provided in this Change of Circumstance Form is true
and complete, and I understand that the information that I provide is subject to review and assessment by the Minister in accordance
with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act. I
understand that this Change of Circumstance Form supplements, amends and forms part of my Original Application.
I acknowledge that the declarations I provided in the Original Application and the declarations and consents I provided in the Master
Student Financial Assistance Agreement - Alberta and the Master Student Financial Assistance Agreement - Canada (see the
Completing your Master Student Financial Assistance Agreement information sheet at studentaid.alberta.ca) also apply to this Change
of Circumstance Form and to the personal information that I have provided in this form.
I understand that if I make a false or misleading statement in this Change of Circumstance Form, fail to disclose information or fail to
notify the Minister of any changes to the information provided in this Change of Circumstance Form, it may result in one or more of
the following: I may be denied financial assistance, be required to immediately repay all financial assistance received, or be subject to
criminal prosecution.

0 7 /1 5 A P P -T Y P E IA A P P -Y E A R 2 0 1 4 /2 0 1 5 A P P - F O R M - A F o r O ffic e U s e O n ly A p p ID

Page 155
Change In Personal Information

LEGAL NAME CHANGE

If your name has changed, complete this section with your previous name(s) and attach a copy of one of the appropriate documents
listed below.

M id d le
Previous First Name initial Previous Last Name

I I I I I I I I I □
CHANGE IN MARITAL STATUS

If your marital status has changed to married or common law, your spouse/partner must complete and sign a Schedule 2.
If your spouse’s/partner’s information has changed, they must provide the revised information on Schedule 2 and explain the
changes in the space provided.

Day Month Year

Date Marital Status Changed:
_I_ J___ L _I__
Marital Status Changed to:
□ Separated/Divorced/Widowed
□ Married
□ Common Law

COMMENTS/ADDITIONAL INFORMATION

DOCUMENTATION REQUIRED

Circumstance Acceptable Documentation (provide copies - do not send originals)

Legal Name Change • Legal Name Change document • Driver’s license

• Marriage certificate • Passport
• Divorce/separation papers

Change in Marital Status • Marriage certificate • Driver’s license

• Divorce/separation papers • Passport

Page 156
Change in Dependent Children Information

If the number of dependent children has changed since you last applied, complete this section. Dependent children means those
children who are living with you and for whom you and/or your spouse/partner are legally responsible. Student Aid Alberta will
consider children over the age of 18 if they are permanently disabled or attending regular high school. If the child you are listing is not
your son or daughter (e.g. niece, nephew, grandchild) or if you have adopted a child, you must provide documentation confirming your
Legal Guardianship (see below).

Day Month Year

Date Changed:
! I I ! J___ I__

Last Name First Name Birthdate (day/month/year) Relationship to you

MONTHLY CHILD CARE COSTS (AFTER SUBSIDY)

Consideration may be given for child care/daycare costs exceeding $75/month/child with appropriate documentation.

Monthly Child Care Cost (after subsidy) $

COMMENTS/ADDITIONAL INFORMATION

DOCUMENTATION REQUIRED

Circumstance Acceptable Documentation (provide copies - do not send originals)

Dependent Children over the age of 18 • If attending regular high school, provide the details in the space above
• If permanently disabled, provide medical documentation showing
your child requires special daily care

Legal Guardianship • Legal Guardianship papers verifying custody of the additional

dependent(s) you are now claiming

Additional Child Care Costs • Current receipt or statement from your child care provider (after subsidy)
OR
• Current receipt or statement from your child care provider showing
amount paid after subsidy

Page 157
Change In Full-Time or Part-Time Studies Information

Complete this section if you are changing programs and/or study start and end dates. You must attach documentation from your
school verifying the changes or your request will not be considered (see below).
There are some situations when you need to submit a new application instead of a Change of Circumstance Form. If the situation(s)
below applies to you, then submit a new Application for Financial Assistance:
you are changing schools/campuses there is a break of 30 days or more between your school terms
your new start date is more than 30 days past your original
start date

Program

1 1
Program Specialization/Major

I I I I I I I I I I
Program Outcome
Are you enrolled in a correspondence/e-learning/distance study program? □ Yes Q No
□ Certificate
What year of this program will you be in? (check one)
□ Diploma
□ 1s' year or less □ 2nd year □ 3rd year □ 4lh or 5lh year
□ Degree
□ Degree - Masters Length of your program of studies (check one)
□ 1 year or less Q 2 years □ 3 years Q 4 or 5 years
□ Degree - Doctoral

Dates 1will attend school Start End

(these dates cannot Day Month Year Day Month Year
exceed 12 months)
_ i_ L i i I J___ L___I___ _ i_ L i i I J___ I___ I___

Will you complete your program of study and receive your

post-secondary certificate, diploma, or degree by the session end date? □ Yes □ No

Educational Costs for Study Period

Tuition $ Books/Supplies/lnstruments $

Mandatory Fees (does not include

$ Computer Costs $
housing/residence costs)

COMMENTS/ADDITIONAL INFORMATION

DOCUMENTATION REQUIRED

Circumstance Acceptable Documentation (provide copies - do not send originals)

Change in Full-time • A detailed letter from the Registrar/Awards Officer at your school indicating your program,
or Part-time study specialization, program outcome, program term dates, and a breakdown of your tuition,
information mandatory fees, and books/supplies.

Extension of study • Medical documentation AND confirmation from your school confirming that your study period end
end dates date has been extended. The maximum extension permitted for medical reasons is one (1) month.

Page 158
Change in Costs and Resources - page 1
C o m p le te o n ly th e in fo rm a tio n th a t n e e d s to b e review e d.

While attending school, I will be living with: □ Parents □ Other

COSTS

Your application has already been assessed for standard living costs (see studentaid.alberta.ca). If you are requesting additional
funding due to high costs, you must provide the appropriate documentation to be considered (see pages 2 and 3).

Date Costs Changed,

Monthly Costs While in School Monthly Amount
if applicable (day/month)

Rent/Mortgage $
I I I I
Utilities (power, water, phone, etc.) $
i I i i
Transportation (to get to and from school) $
I I I I
Medical (costs not covered by insurance) $
i I i i
Child Support Payments you make $
I I I I
Other (provide explanation on next page) $
i I i i
Total Monthly Costs $

RESOURCES

Date Income Changed,

Monthly Resources While in School Monthly Amount
if applicable (day/month)

Wages/Salary (net income) $

I
Assistantships after deductions $
I
Stipends $
I
RESP and Voluntary Contributions from Parents $
I
Alimony and/or Child Support you receive $
I
Employment Insurance (El Benefits) $
I
Assured Income for the Severely Handicapped (AISH) $
I
Workers’ Compensation Benefits $
I
Aboriginal Affairs and Northern Development Canada/Band Funds $
I
Other Income (pensions, rental property, business) $
I
Total Monthly Resources $

(continued next page)

Page 59
Change in Costs and Resources - page 2
C o m p le te o n ly th e in fo rm a tio n th a t n e e d s to b e review e d.

OTHER RESOURCES AVAILABLE TO ME

Savings you will have when you start school $

Assets (e.g. Tax-Free Savings Account, bonds, stocks, GICs, etc.) $

Registered Retirement Savings Plans (RRSPs) $

Other Resources List: $

Scholarships (e.g. Rutherford, Athletic, Louise McKinney, other) $

COMMENTS/ADDITIONAL INFORMATION

Page 60
Change in Costs and Resources - page 3

DOCUMENTATION REQUIRED

Circumstance Acceptable Documentation (provide copies - do not send originals)

Requesting Tuition and Books Only
If your resources exceed the costs Student Aid Alberta
considers, you can request to receive funding to cover
the costs of your tuition and books.
• A detailed budget outlining the amount of your family’s
monthly costs.
• A list of your available resources

Additional Rent and Utilities • Copies of rent receipts or lease agreements

Consideration may be given for rent or mortgage
costs, property taxes, condo fees, and standard
utility payments.
• Mortgage agreements
• Copies of basic utility bills (e.g. power, natural gas, water, sewer,
garbage, phone) Cable, satellite, and internet are not considered
basic utilities.

Child Support/Alimony Payments • Proof of payment for the last four months, AND
made by you or your spouse/partner
• Maintenance Enforcement report, copy of court order, or a letter
Consideration may be given if you pay child
signed by your ex-spouse/partner that confirms the amount you
or spousal/partner support.
pay monthly

Transportation
Additional travel costs may be considered for students
when it is more economical to commute to school
rather than relocate.
• Provide the distance it takes to travel from your residence to your
school (e.g. printout of a map)
• Receipts showing your basic vehicle insurance costs (PL/PD only)

Medical/Dental/Optical • Receipts and associated medical documentation.

Medical expenses that are not covered through
Alberta Health Care or your student health plan may
be considered.

Aboriginal Affairs and Northern Development • Provide confirmation from the band stating the monthly amount and
Canada/Band Funds whether the band will cover tuition, fees, and books.

DOCUMENTATION REQUIRED FOR OTHER EXCEPTIONAL CIRCUMSTANCES

Circumstance Acceptable Documentation (provide copies - do not send originals)

Additional Tuition, Fees, and Books • Provide documentation from an authorized official from your
If your actual costs are higher than what your educational institution confirming your actual education costs.
educational institution has provided to Student
Aid Alberta, consideration can be made for your
high tuition.

Second Residence • Copies of rent receipts or lease agreements

If you are living apart from your spouse/partner
• Mortgage agreements
to attend school.
• Copies of basic utility bills (e.g. power, natural gas, water, sewer,
garbage, phone) Cable, satellite, and internet are not considered
basic utilities.

Student Loan Payments made by your • Provide a statement from the service provider confirming the
spouse/partner amount of the monthly payments.
If your spouse/partner is currently repaying a
government student loan, the cost of those payments
may be considered.

Other • Provide supporting documentation and/or receipts.

Other exceptional expenses may be considered.

Page 61
Charles S. Noble
Junior Football
Scholarship

Page 162
 CHARLES S. NOBLE JUNIOR FOOTBALL SCHOLARSHIP

The Charles S. Noble Junior Football Scholarship honours the agricultural entrepreneur, innovator and farm implement
manufacturer who became one of Alberta’s biggest and best grain farmers.

The Charles S. Noble Junior Football Scholarship rewards the athletic and academic excellence of junior football players at
universities, colleges and technical institutes in Alberta.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the three Alberta Junior Football Teams.

Award Value - $1,000

Eligibility

Applicant must:
a. be a Canadian citizen or Permanent Resident and be an Alberta resident,
b. be a playing member on an Alberta Junior Football team,
c. be enrolled as a full-time student at a post-secondary institution in Alberta and maintaining an academic standing of at least
65% or a GPA of 2.0 on a GPA scale of 4.0, and
d. be recommended by the Scholarship Committee of the Alberta Junior Football teams.

Scholarships will be paid in two installments of $500 each on December 1 and April 1. Recipients must continue to meet the
eligibility criteria in order to receive the second installment.

Selection Procedures

Nominations from each Junior Football Team in Alberta (Edmonton Wildcats, Edmonton Huskies, and the Calgary Colts) are
forwarded to the Scholarship Committee. The Committee will select a maximum of ten nominees from each team in any given year
and forward the recommendations to Alberta Scholarship Programs for final approval.

FAXED APPLICATIONS ARE HOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Application Deadline: October 1

Page 163
 CHARLES S. NOBLE JUNIOR FOOTBALL SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
You m ay use the Learner Registry at w w w .e d u e a t io n .g o v .a b .c a . to find your Alberta Student N um ber or to have one assigned.

Alberta Student Nuriber ( r e a u i r e d fo r D ro c e s s n e ) Social Insurance Number re q u ire d fo r p r o c e s s in g

Last Name (current full legal name) Please use upper and low er case. First Name and One Initial (current full legal name)

Mailin 2 Address (include Am . or Box Num ber) Citv/T()\vn

Previous Surname
Province Country Postal Cods Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M F mtpnth
__ i ycP i__

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N

Have you livec in Alberta all your life? I f your pa r e n t s d o n o t c u r r e n t l y r e sid e in A l be r t a AND y o u h ave n o t l iv e d in
A lberta a l l y o u r l if e , p l e a se in c l u d e a l e t t e r e x p l a in in g t h e t im e sp e n t in
Y N Since njonth | >jcar |
A lbe r t a a s a n o n f u l l - t im e s t u d e n t .

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Institution City Entry Date for Program Program

T°"lhl i iyear i
POST-SECONDARY STUDENT I.D. NUMBER

Office Use Only

89 8 0 3 © 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u rs e m e n t
Dec 1 - 500
19 E
Apr 1 - 500
SPORT MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: March 2013

Page 164
 Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility, and if I do not want to be identified I will contact Alberta Scholarship Programs.

S ig n a tu re o f A p p lican t T o d a y ’s D a t e ( i n i n k )

This Section to be Completed by the Nominating Team

Name of Team: _____________________________________________________

Name of Official:

Position:

Signature of Official:

Page 165
Charles S. Noble
Junior Hockey
Scholarship

L 4 j b e t t * j
Page
 CHARLES S. NOBLE JUNIOR HOCKEY SCHOLARSHIP

The Charles S. Noble Junior Hockey Scholarship honours the agricultural entrepreneur, innovator and farm implement manufacturer
who became one of Alberta’s biggest and best grain farmers.

The Charles S. Noble Junior Hockey Scholarship rewards the athletic and academic excellence of Junior Hockey players and
provides an incentive and means for these players to continue with their post-secondary education.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the Friends of Alberta Junior Hockey Society.

Award Value -1 0 awards of $2,000

Eligibility Criteria

Applicant must:
a. be a Canadian citizen or Permanent Resident and be an Alberta resident,
b. be a participant, or have been a participant, in at least one full season of hockey in the Alberta Junior Hockey league
and have played during the last year or are currently playing,
c. be enrolled as a full-time student at a post-secondary institution in Alberta and and maintaining an academic standing of at
least 65% or greater or a grade point average of 2.0 on a 4.0 scale, and
d. be recommended by the Scholarship Committee of the Friends of Alberta Junior Hockey Society.

Selection Procedures

Nominations from each Junior Hockey Team in Alberta are forwarded to the Scholarship Committee. Each nomination must include
a current transcript and attachments outlining the applicant’s extra curricular activities and future goals.

The Committee will select recipients based on academic standing, community involvement and hockey achievements.

FAXED APPLICATIONS ARE SOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a S100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Application Deadline is December 1

Page 167
 CHARLES S. NOBLE JUNIOR HOCKEY SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone: 780.427.8640.

Personal Information
You may use the Learner Registry at w w w .e d u c a tio n .g o v .a b .ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

_____ I I I I I I I I I I I I I I Previous Surname __________________________

Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

month
___T i yr i

CITIZENSHIP (check one)

1 C A N A D IA N C IT IZ E N or I P E R M A N E N T R E S ID E N T (L an d e d Im m ig ra n t)
1------ 1 1------ 1 Note: Attach a photocopy of permanent resident card. Visa students are not eligible.

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N

Have y< a lived in Alberta all your life? I f your pa r e n t s d o n o t c u r r e n t l y r e sid e in A l be r t a A N D y o u ha v e n o t l iv e d in

Y N Since A l be r t a a l l y o u r like , p l e a se in c l u d e a l e t t e r e x p l a in in g t h e t im e sp e n t in
A lberta a s a n o n f u l l - t im e s t u d e n t .

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Institution City Entry Date for Program _______ Program

I I I II I I I I I I I I I nP thl i y<iar i ______________

POST-SECONDARY STUDENT I.D. NUMBER

Office Use Only

89 8 0 5 © 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u rs e m e n t

21 E
SPORT MO YR ASP AUTHORIZATION AWARD KEY APP KEY
Revised: October 2014
Page 168
 Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation and program promotion.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Section to be Completed by the Nominating Team

Name of Team: ___

Name of Official: __

Position: __________

Signature of Official:

Page 169
 HOCKEY RECORD
Note: To be considered, players must have played in the Junior Hockey League last year or be currently playing,

a. List Junior teams played for and years played:

b. Statistical Record (past and current years)

c. Awards or distinctions received (scholastic/sports)

ON AN ATTACHED PAGE PLEASE PROVIDE THE FOLLOWING:

1. A short summary outlining your extra curricular activities within the community during the past few years. The statement
should be typed and no more than one page in length, and

2. A brief outline of your future plans/goals. Again this should be typed and no longer than one page.

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships

Page 170
 Charles S. Noble
Scholarship for Study at
Harvard

Page 171
 Charles S. Noble Scholarship for Study at Harvard
The Charles S. Noble Scholarship honours Sandy A. Mactaggart, the agricultural entrepreneur, innovator and farm
implement manufacturer who became one of Alberta’s biggest and best grain farmer.

Sandy A. Mactaggart graduated from Harvard and became a highly successful business entrepreneur. Since 1952, he
has been actively involved in the development of properties as well as oil and gas venture capital. Mr. Mactaggart has
established this endowment as a means of expressing his gratitude for an education which has broadened his ability to
enjoy and contribute to life in Alberta. These scholarships recognize and reward academic excellence and provide an
opportunity for outstanding Alberta students to pursue undergraduate studies at Harvard.

Up to three scholarships of $10,000 each

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have
resided in Alberta during the qualifying grades, and
b. intend to apply or be enrolled full-time in an undergraduate program at Harvard.

Selection Procedure
Recipient are selected by the Office of Admissions at Harvard University and their recommendations are forwarded to
Alberta Scholarship Programs.

The award will be disbursed in November after Alberta Scholarship Programs confirms full-time enrollment in post­
secondary studies.

Application Procedure

Mail completed application to:

Office o f Financial Aid

Harvard College
86 Brattle Street
Cambridge, MA 02138

For further information contact:

Alberta Scholarship Programs
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Application Deadline: May 15

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage
Scholarship Fund is designed to stimulate the pursuit of excellence by recognizing outstanding achievement
and by encouraging and assisting Albertans to achieve their fullest potential.

Page 172
 Charles S. Noble Scholarship for Study at Harvard
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
information, please contact Alberta Scholarship Programs, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number (to obtain an ASN go to www.education.gov.ab.ca) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M day month year
_ l___ ___ I__ l___I___ I___ L

CITIZENSHIP (check one)

□ CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.

ALBERTA RESIDENCY
Do your parents currently live in Alberta?
Y N

Have you lived in Alberta all your life?

If you have answered “NO” to either of these questions, please include a
Y N Since month year
___I______ I___ I___ I__ letter explaining your residency.

POST-SECONDARY STUDIES
Name of Institution Year of Program - Circle One
H A R V A R D 1st 2nd 3 rd 4th
Name of Program: Start Date of Program

i I i___I___]_
Month Year

Office Use Only

Revised: April 2013

Page 173
 Personal Information (continued)

Please indicate if you will be receiving financial assistance and the amount of support expected:

Harvard: ________________________________________________________________________

Other agencies (list): ________________________________________________________________

None: ___________________________________________________

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRU CTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between Alberta
Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and Harvard University for the purpose of determining my eligibility for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs is available at:
alis.alberta.ca/scholarships

Page 174
 CHEQUE TRANSFER TO LOANS ADMINISTRATION

N a m e:____________________

S IN :______________________

Cheque/Money Order Date:__

Cheque/Money Order Number:

A m ount:___________________

Comments:

Received by: Date:

Page 175
 China-Alberta
Award for Excellence
in Chinese

Page 176
 China-Alberta Award for Excellence in Chinese
This scholarship is a collaborative scholarship program supported by the Education Office in the Consulate-General of The People’s
Republic of China in Vancouver and Alberta Education. The award was created in 2013 from contributions by the Education Office
in the Consulate General of the The People’s Republic of China in Vancouver and the Government of Alberta to facilitate Chinese
language and culture promotion in Alberta.

Award Value - $500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parents or a parent must
reside in Alberta,
b. have taken Chinese Language and Culture 10-3Y, 20-3Y and currently be enrolled or have completed 30-3Y,
c. have obtained an average of 80% in all courses, and a minimum average of 90% in Chinese 10-3Y and 20-3 Y, and
d. be currently enrolled in Grade 12.

Selection Procedure
The applicant will be selected by a committee designated by Alberta Education who will review each student’s marks, a two
paragraph essay and a teacher and/or school recommendation.

Application Procedure*•

Submit to Alberta Scholarship Programs a:

• completed application form,
• two paragraph essay on “how will what you learned in the Chinese language and culture program apply to your future
studies and/or career”,
• a letter of recommendation, and
• a copy of your high school transcript.

Students will be notified of the status of their application in September.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Application Deadline: June 30

Page 177
 China-Alberta Award for Excellence in Chinese
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt, or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M <)ay | m^nlh | [ yepr ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? I f ‘NO’ since
Y N Y N month year
___ I___ ___ I____I____I___
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month I year month I year
_i___I___i i
Institution City Length of Program Year of Program

0 2nd 3rd 4th

Office Use Only

128 8 8 8 1 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Disbursement

MO YR AUTHORIZATION AW ARD KEY APP KEY

Revised: March 2013

Page 178
 Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if 1 do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships

Page 179

Student A id Alberta
The Completion Incentive Grant is awarded to you if you will
complete a credential between August 1,2012 and July 31,
2015 AND if you received full-time post-secondary student aid
at any point during your studies for that credential.
Most students will get the Completion Incentive Grant
automatically. But, you will have to submit this paper application if:
- you are in your final year of studies, did not receive student aid
for your final year but did receive student aid for previous years
of study, or
- you did not indicate that you are in your final year of studies
on your application for student aid
Student Aid Alberta must receive this application within your
final semester of studies before your program session end date.
Application for the 2014/2015 14/15
Completion Incentive Grant CIG
Innovation and Advanced Education is collecting this personal
information under the authority of section 33(c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“ FOIP”) to
determine and verify your eligibility for financial assistance and to
administer and enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta)
as may be amended from time to time. The use and disclosure of
your personal information is managed in accordance with FOIP.
If you have any questions about the collection, use or disclosure
of this information, call the Student Aid Alberta Service Centre toll
free at 1-855-606-2096 from anywhere in North America. You can
also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

P E R S O N A L IN F O R M A T IO N

Last Name (current full legal name) Social Insurance Number

J__ I__ I__ I__ L

Middle
First Name (current full legal name) Initial Day Month Year
Birthdate
I I I I I I I I I I I I I I I I U _ l I i i 1 _ J _____1_____1_____
If you have changed your name since you last applied, Marital Status: (check one)
provide legal documentation.
— I Single (no dependent children)
Apartment or Box Number
_| Separated/Divorced/Widowed
(no dependent children)
I Single Parent/Separated/Divorced/Widowed
Street Address
(with dependent children)
J Married
CityATown □ Common Law

Maiden Name (if applicable)

Prov/State Country Postal/Zip Code 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 Your Alberta Student Number (mandatory)
(obtained from Alberta High School Transcript)
Telephone (format: 999-999-9999)
J__ I__ I__ I__ I__ L
J___I I I I I I I I
Alternate Telephone (format: 999-999-9999)

O FFIC E USE O N LY - DO N O T W R IT E B E L O W T H IS LIN E

Identify the CIG Credential and Amount (only one) I I DE - Degree Undergraduate $
1 1 1 1
□ C - Certificate $ □ DM - Degree Masters ^

□ D - Diploma j □ DP - Degree Doctoral $

I I I I
Day Month Year
A S C L K Date Assessed
_I_ J___L _I__
A P P - T Y P E 1 51 A P P - Y E A R 2 0 1 4 / 2 0 1 5 F o r O ffic e U s e O n ly A p p ID

A P P L IC A N T C O N S E N T A N D D E C LA R A T IO N on n e x t p a g e
Page 180
 Page 2

FULL-TIME STUDIES INFORMATION

Educational Institution Program Outcome

I I I I I I I I I I I I I I I I I I I I I I □ Certificate u Diploma I_| Degree

City/Town Prov/State u Degree - Masters

I I I I I I I I I I I I I I I I I I I
u Degree - Doctoral

Country

I I I I I
Enter your program session start and end
Program dates for the 2014/2015 school year.
1 1 1 Start
Program Specialization/Major Day Month Year

I ■ I I I

I will complete my program of study and receive a post-secondary ,— —.

End
credential (certificate, diploma, or degree) by the session end date. '— I Yes —' No
Day Month Year
I received student aid during my studies for my credential. |_ | Yes No
I ■ I I I

APPLICANT CONSENT AND DECLARATION

I declare and warrant that:
• the information that I have provided in this Application is true
and complete and I understand that the information that I have
provided is subject to review and assessment by Innovation
and Advanced Education in accordance with the Student
Financial Assistance Act (Alberta).
• I will use any financial assistance awarded to me toward the
costs of my education.
I understand that I have an obligation to:
• immediately notify Innovation and Advanced Education in
writing of any change in my name, address, academic status
or study period, or to any other information contained in this
Application.
• provide information or documents as requested by Innovation
and Advanced Education to verify any statements made in
this Application.
I understand that:
• I may be required to immediately repay any financial assistance
I receive if there are any changes to my academic status or
study period.
• I may be denied financial assistance if I fail to notify Innovation
and Advanced Education in writing of any change in my
academic status or study period, or fail to provide documents
or information as requested by Innovation and Advanced
Education to verify statements made in this Application.
• if I make a false or misleading statement in this Application,
or fail to disclose information as requested by Innovation and
Advanced Education, I may be denied financial assistance,
and/or required to immediately repay all financial assistance
received, and/or subject to criminal prosecution.
• failure to disclose information or provide updated information
as requested by Innovation and Advanced Education may
constitute the making of a false or misleading statement.
• Innovation and Advanced Education has the right to recover
financial assistance I receive that I am not entitled to, including
any financial assistance I receive due to administrative errors.
I also acknowledge the authority of, and where a consent
is required hereby irrevocably authorize Innovation and
Advanced Education to disclose and exchange my personal
information with:
• any educational institution to verify any information I have
provided to Innovation and Advanced Education, to administer
student financial assistance programs, to determine my
eligibility for financial assistance and to respond to my inquiries
concerning the status of my Application or any financial
assistance awarded;
• federal government departments or agencies or the
educational institution(s) named in this Application to conduct
research, statistical analysis, and evaluations related to student
financial assistance programs;
• any of the following: lending institutions; credit bureaus; the
educational institution named in this Application; and any third
party authorized to collect a debt owed to Her Majesty the
Queen in right of Alberta, in each case for any purposes related
to administration, enforcement or collection related to student
financial assistance programs;
• Employment and Social Development Canada through the
Social Insurance Registry to verify my Social Insurance
Number, name, date of birth, and gender. This verification will
be done solely to confirm my identification for the purpose of
this Application for funding.

Applicant Signature Today’s Date

Day Month Year

i I i i J___ I___ L
UPLOAD instructions: Complete and save the document to your computer. Login to SFS to upload.
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4
Page 181
Concurrent Enrollment 2014/2015 Schedule 3
Exchange/Field Study Programs 14/15 S3
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify your eligibility for financial assistance, to administer (including
research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the Student Financial
Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended from
time to time. The use and disclosure of your personal information is managed in accordance with FOIP. If you have any questions about the
collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Applicant s Last Name Initials Social Insurance Number

PART 1: CONCURRENT ENROLLMENT (see Quick Tips, p.13 #8)

Concurrent enrollment means you are simultaneously attending more than one school on a part-time basis
(less than 60% of a full-time course load at each education institution).
• If you are concurrently enrolled, enter your primary educational institution on Page 2 of this application
(Full-time Studies Information section)
• You must choose one of the institutions as your “ primary institution” . Your primary institution will be responsible for confirming
your registration.
• Your course(s) at each school will be reviewed to determine whether you can be considered a full-time student for student
aid purposes.

Enter your primary institution:

1 1 1 1

Enter your additional institution(s):

I I I I I I I I I I I I I I

I I I I I I I I I I I I I

To verify full-time status, you must attach documents from your primary and additional institutions stating:
• Course Name(s)
• Course Weight(s)/Credit(s)
• Session Start and End Dates
• Course Costs

PART 2: EXCHANGE/FIELD STUDY STUDENTS ONLY

Enter your home educational institution:

Note: Your home institution is where tuition costs are paid and is also listed in the Full-time Studies Information section on Page 2
of this application.
Attach a letter of confirmation from your home institution or an acceptance letter from the host institution. Your letter should confirm
the actual start and end dates of your Exchange or Field Study Program and list your costs for Tuition, Mandatory Fees, and Books.

What is your airfare cost (if applicable)?

UPLOAD instructions: Complete and save the document to your computer. Login to SFS to upload.
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4 Page 182
Concurrent Enrollment 2015/2016 Schedule 3
Exchange/Field Study Programs 15/16 S3
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify your eligibility for financial assistance, to administer (including
research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the Student Financial
Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended from
time to time. The use and disclosure of your personal information is managed in accordance with FOIP. If you have any questions about the
collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Applicant s Last Name Initials Social Insurance Number

Part 1: Concurrent Enrollment (see Quick Tips, p.13 #8)

Concurrent enrollment means you are simultaneously attending more than one school on a part-time basis
(less than 60% of a full-time course load at each education institution).
• If you are concurrently enrolled, enter your primary educational institution on Page 2 of this application
(Full-time Studies Information section)
• You must choose one of the institutions as your “ primary institution” . Your primary institution will be responsible for confirming
your registration.
• Your course(s) at each school will be reviewed to determine whether you can be considered a full-time student for student
aid purposes.

Enter your primary institution:

Enter your additional institution(s):

I I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I I I I I I I I I I
To verify full-time status, you must attach documents from your primary and additional institutions stating:
• Course Name(s)
• Course Weight(s)/Credit(s)
• Session Start and End Dates
• Course Costs

Part 2: Exchange/Field Study Students Only

Enter your home educational institution:

I I I I I I I I I I I I I I I I I I I I I I I I I

Note: Your home institution is where tuition costs are paid and is also listed in the Full-time Studies Information section on Page 2
of this application.
Attach a letter of confirmation from your home institution or an acceptance letter from the host institution. Your letter should confirm
the actual start and end dates of your Exchange or Field Study Program and list your costs for Tuition, Mandatory Fees, and Books.

What is your airfare cost (if applicable)?

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4
Page 1183

Confirmation of Registration-Reinstatement of
Student Aid Alberta Interest Free Status for Alberta Student Loans*
Service Centre
Instructions and Information
Complete this form only if you are returning to school a) as a full-time student and are not receiving new Alberta
and/or Canada Student Loans, or b) as a part-time student.
Instructions to Students and Key Dates
1. Complete all areas in Section 1.
2. Take the form to the educational institution you are attending
and have them complete Section 2. Make sure they make a
copy to keep for their records.
KEY DATES: Your educational institution can confirm
registration up to 30 days prior to your Academic Start
Date but cannot confirm registration after the Academic
Year End Date.
3. Make copies of the completed Form B.
• Send one copy to the Student Aid Alberta Service Centre.
Address is in the right column.
KEY DATES: The Student Aid Alberta Service Centre
must receive this form within 30 days after your
educational institution has signed it. Also, this form
cannot be accepted after your Academic Year End Date.
• Send copies to Royal Bank and/or CIBC if you have
loans at either bank. Addresses are in the right column.
• Keep a copy for your records.
Important Tips
• If you are returning to school full-time and are receiving new
Alberta and/or Canada Student Loans, your previous Alberta
Student Loans at the Student Aid Alberta Service Centre will
automatically be reinstated to interest free status.
• If you are a full-time student and reinstate interest free status
on your Alberta Student Loans using this form, your Canada
Student Loans with the National Student Loans Service
Centre will automatically be reinstated to interest free status.
You do not have to complete another form for your Canada
Student Loans.
• If you have Alberta Student Loans at Royal Bank or CIBC
or if you have Alberta Student Loans in collection, they may
automatically be transferred to the Student Aid Alberta Service
Centre for interest-free status when you return to studies. For
the transfer to happen, the loan payments must be up to date
and you must not be involved in bankruptcy proceedings.
• If you are a part-time student or a medical resident, only your
Alberta Student Loans will be reinstated to interest free status.
Form B
*For definition of Alberta Student Loan, see bottom of page.
Mailing Addresses
Student Aid Alberta Service Centre
PO Box 4050
Mississauga STN A
Mississauga ON L5A 4M9
Royal Bank Student Loans Centre
PO Box 4700 STN D
Etobicoke ON M9A4X5
1-800-363-3822
CIBC Student Loans Centre
PO Box 5055
Burlington ON L7R 4P3
1-800-563-2422
For More Information on Your Alberta Student
Loans, Contact:
• Student Aid Alberta Service Centre toll-free at
1-855-606-2096, Monday to Friday, 7:30 a.m.
to 8:30 p.m. your local time, in North America
- Outside North America toll-free at
800 2 529-9242, plus appropriate country code
- For the hearing impaired, toll-free TTY number
at 1-855-306-2240
• The financial aid office at your education institution
• studentaid.alberta.ca
Register for Student Aid Alberta Service Centre’s
Online Services at studentaid.alberta.ca to manage
your Alberta Student Loans online.
*Definition of Alberta Student Loan
“Alberta Student Loan" collectively means all loans
made to the Student pursuant to any of the Alberta
Student Finance Acts [the Students Finance A ct
(Alberta), the Student Loan A ct (Alberta) and the Student
Financial Assistance A ct (Alberta), and any regulations
made under these Acts, each as may be amended from
time to time], including loans made to the Student by
the Minister, loans made to the Student by a financing
institution and transferred to the Minister, loans made
while the Student was a minor, and also including any
grant overpayments converted to a loan by the Minister
under the Alberta Student Finance Acts.
Page 84
 Form B
Confirmation of Registration-Reinstatement of
Student Aid Alberta Interest Free Status for Alberta Student Loans*
Service Centre
*For definition of Alberta Student Loan, see bottom of previous page.

Complete this form only if you are returning to school a) as a full-time student and are not receiving new Alberta and/or Canada Student
Loans, or b) as a part-time student.
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom o f Information
and Protection o f Privacy A ct (Alberta) to determine and verify your eligibility for reinstatement of the interest free status of your Alberta Student Loan
in accordance with the Student Financial Assistance A ct (Alberta) as may be amended from time to time. The use and disclosure of your personal
information is managed in accordance with the Freedom o f Information and Protection o f Privacy Act (Alberta). If you have any questions about
the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to the Student Aid Alberta Service Centre, Executive Customer Assistance Department, PO Box 4050,
Mississauga Stn A, Mississauga ON L5A 4M9.

Section 1 - To be Completed by the Student

Last Name First Name and Initial(s)

J__ I__ I__ L J__ I__ I__ I__ L __I__ L J __ I__ I__ L J__ I__ I__ L J__ L J __ L
Apartment or Box Number Social Insurance Number
_ J __ I__ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L
Street Address I I I
Alberta Student Number
__ I__ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L
City or Town
J___I___ I___L J___ I___ I___ L
_ l __ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L Email Address
Province Postal Code

J__ I__ I__ L I I I

Area Code Telephone Number

I__ I_ | I I I I
F ederal In stitu tio n C o d e A lb e rta In stitu tio n C o d e
Section 2 - To be Completed by the Educational Institution
i i i ___ l___ i___ i__
Name, Address and Postal Code of Designated Educational Institution The Period of Study cannot exceed 12 calendar months.
A cadem ic S tart Date A cadem ic Year End Date
Period D M Y M Y
of Study
____I____ ____I____ ____I____I____ I____ ____I____ ____I____ I____ I___
This will confirm that the student named above is studying at this educational
institution for the period of study dates indicated above, and is registered as a:
□ full-time student □ student with a permanent disability studying
□ part-time student at 40-59% of a full course load
□ medical resident

Name of Authorized Officer: Title:

Signature of Authorized Officer: Today’s Date:

D i M
_ i __ L l
Area Code Telephone Number This confirmation is valid for up to 30 days from this date,
I I I I I I I I
but not beyond the Academic Year End Date. — i
I I
Section 3 - Notice of Withdrawal - To be Completed by the Educational Institution
If the student leaves full-time or part-time studies before the Academic by email to COR-AB@gov.ab.ca [include the Student Name,
Year End Date, complete and forward this form to Student Aid Alberta: Alberta Student Number, Last Day Attended, Withdrawal Reason,
• by fax to 780-415-0448 Withdrawal Date, and Student ID (if known)]
Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4

Printed Name of the Authorized Officer of Educational Institution:

Indicate Last Day of Attendance

□ Withdrew from full-time studies □ Transferred to part-time studies Signature of the Authorized Officer of Educational Institution:
□ Withdrew from part-time studies □ Early completion
□ Did not attend □ Other
Title: Date:
Reason for Withdrawal (if other):

(revPJISfcdftP

Confirmation of Registration-Reinstatement of
Student Aid Alberta Interest Free Status for Alberta Student Loans*
Service Centre
Instructions and Information
Complete this form only if you are returning to school a) as a full-time student and are not receiving new Alberta
and/or Canada Student Loans, or b) as a part-time student.
Instructions to Students and Key Dates
1. Complete all areas in Section 1.
2. Take the form to the educational institution you are attending
and have them complete Section 2. Make sure they make a
copy to keep for their records.
KEY DATES: Your educational institution can confirm
registration up to 30 days prior to your Academic Start
Date but cannot confirm registration after the Academic
Year End Date.
3. Make copies of the completed Form B.
• Send one copy to the Student Aid Alberta Service Centre.
Address is in the right column.
KEY DATES: The Student Aid Alberta Service Centre
must receive this form within 30 days after your
educational institution has signed it. Also, this form
cannot be accepted after your Academic Year End Date.
• Send copies to Royal Bank and/or CIBC if you have
loans at either bank. Addresses are in the right column.
• Keep a copy for your records.
Important Tips
• If you are returning to school full-time and are receiving new
Alberta and/or Canada Student Loans, your previous Alberta
Student Loans at the Student Aid Alberta Service Centre will
automatically be reinstated to interest free status.
• If you are a full-time student and reinstate interest free status
on your Alberta Student Loans using this form, your Canada
Student Loans with the National Student Loans Service
Centre will automatically be reinstated to interest free status.
You do not have to complete another form for your Canada
Student Loans.
• If you have Alberta Student Loans at Royal Bank or CIBC
or if you have Alberta Student Loans in collection, they may
automatically be transferred to the Student Aid Alberta Service
Centre for interest-free status when you return to studies. For
the transfer to happen, the loan payments must be up to date
and you must not be involved in bankruptcy proceedings.
• If you are a part-time student or a medical resident, only your
Alberta Student Loans will be reinstated to interest free status.
Form B
*For definition of Alberta Student Loan, see bottom of page.
Mailing Addresses
Student Aid Alberta Service Centre
PO Box 4050
Mississauga STN A
Mississauga ON L5A 4M9
Royal Bank Student Loans Centre
PO Box 4700 STN D
Etobicoke ON M9A4X5
1-800-363-3822
CIBC Student Loans Centre
PO Box 5055
Burlington ON L7R 4P3
1-800-563-2422
For More Information on Your Alberta Student
Loans, Contact:
• Student Aid Alberta Service Centre toll-free at
1-855-606-2096, Monday to Friday, 7:30 a.m.
to 8:30 p.m. your local time, in North America
- Outside North America toll-free at
800 2 529-9242, plus appropriate country code
- For the hearing impaired, toll-free TTY number
at 1-855-306-2240
• The financial aid office at your education institution
• studentaid.alberta.ca
Register for Student Aid Alberta Service Centre’s
Online Services at studentaid.alberta.ca to manage
your Alberta Student Loans online.
*Definition of Alberta Student Loan
“Alberta Student Loan" collectively means all loans
made to the Student pursuant to any of the Alberta
Student Finance Acts [the Students Finance A ct
(Alberta), the Student Loan A ct (Alberta) and the Student
Financial Assistance A ct (Alberta), and any regulations
made under these Acts, each as may be amended from
time to time], including loans made to the Student by
the Minister, loans made to the Student by a financing
institution and transferred to the Minister, loans made
while the Student was a minor, and also including any
grant overpayments converted to a loan by the Minister
under the Alberta Student Finance Acts.
Page 86
 Form B
Confirmation of Registration-Reinstatement of
Student Aid Alberta Interest Free Status for Alberta Student Loans*
Service Centre
*For definition of Alberta Student Loan, see bottom of previous page.

Complete this form only if you are returning to school a) as a full-time student and are not receiving new Alberta and/or Canada Student
Loans, or b) as a part-time student.
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom o f Information
and Protection o f Privacy A ct (Alberta) to determine and verify your eligibility for reinstatement of the interest free status of your Alberta Student Loan
in accordance with the Student Financial Assistance A ct (Alberta) as may be amended from time to time. The use and disclosure of your personal
information is managed in accordance with the Freedom o f Information and Protection o f Privacy Act (Alberta). If you have any questions about
the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to the Student Aid Alberta Service Centre, Executive Customer Assistance Department, PO Box 4050,
Mississauga Stn A, Mississauga ON L5A 4M9.

Section 1 - To be Completed by the Student

Last Name First Name and Initial(s)

J__ I__ I__ L J__ I__ I__ I__ L __I__ L J __ I__ I__ L J__ I__ I__ I__ I__ I__ I__ I__ I__ I__ L
Apartment or Box Number Social Insurance Number
_ J __ I__ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L
Street Address
Alberta Student Number
__ I__ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L
City or Town
_ l___I___I___I___I___ I___I___I___I___L
_ l __ I__ I__ I__ I__ L J__ I__ I__ I__ I__ I__ L Email Address
Province Postal Code

J__ I__ I__ L J___ I___ L

Area Code Telephone Number

I__ I_ | I I I I
F ederal In stitu tio n C o d e A lb e rta In stitu tio n C o d e
Section 2 - To be Completed by the Educational Institution
i i i ___ l___ i___ i__
Name, Address and Postal Code of Designated Educational Institution The Period of Study cannot exceed 12 calendar months.
A cadem ic S tart Date A cadem ic Year End Date
Period D M Y M Y
of Study
____I____ ____I____ ____I____I____ I____ ____I____ ____I____ I____ I___
This will confirm that the student named above is studying at this educational
institution for the period of study dates indicated above, and is registered as a:
□ full-time student □ student with a permanent disability studying
□ part-time student at 40-59% of a full course load
□ medical resident

Name of Authorized Officer: Title:

Signature of Authorized Officer: Today’s Date:

D i M
_ i __ L_i_
Area Code Telephone Number This confirmation is valid for up to 30 days from this date,
I I I I I I I
but not beyond the Academic Year End Date. — i
I I I
Section 3 - Notice of Withdrawal - To be Completed by the Educational Institution
If the student leaves full-time or part-time studies before the Academic by email to COR-AB@gov.ab.ca [include the Student Name,
Year End Date, complete and forward this form to Student Aid Alberta: Alberta Student Number, Last Day Attended, Withdrawal Reason,
• by fax to 780-415-0448 Withdrawal Date, and Student ID (if known)]
Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4

Printed Name of the Authorized Officer of Educational Institution:

Indicate Last Day of Attendance

□ Withdrew from full-time studies □ Transferred to part-time studies Signature of the Authorized Officer of Educational Institution:
□ Withdrew from part-time studies □ Early completion
□ Did not attend □ Other
Title: Date:
Reason for Withdrawal (if other):

(revPJISfcd&T
Canadian Oil Sands Network for
Research and Development
(CONRAD) Scholarship
 Canadian Oil Sands Network for Research and Development
(CONRAD) Scholarship
The Canadian Oil Sands Network for Research and Development Scholarship recognizes the accomplishments of students in their
final year of study at the undergraduate and graduate level and who are involved in projects that show commercial potential and/or
relevance.

Eligibility Criteria
Applicants must be:
a. a Canadian Citizen or a Permanent Resident of Canada,
b. attending a post-secondary institution in Alberta,
c. enrolled full-time in their final year of study in a diploma, undergraduate degree, or graduate level program,
d. enrolled in a program of study relevant to oil sands technology development from mine or reservoir to tailings and
remediation such as but not limited to Natural or Biological Sciences and Engineering, and
e. achieve a minimum GPA of 3.0 on a 4.0 grade point scale.

Value of Award - 2 awards of $5,000

Application Procedure
Complete the application form and include the following:

• an official academic transcript,

• a one page summary of the project and its commercial potential, and
• a letter of support from at least one supervising professor or instructor, and if applicable a supporting letter by a
sponsoring company.

Submit the application form and supporting documents to Alberta Scholarship Programs.

Selection Procedure
A selection committee comprised of representatives from former CONRAD Member companies will review transcripts and
applications and determine which students have developed and are working on technologies, innovations or processesses with the
highest probability of being commercially deployed within a reasonable timeframe. The committee will also determine and rank the
likelihood of commercial viability of the projects under evaluation.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1
Alberta Scholarship Programs
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

A p p lication D eadline is O cto b er 31

Page 189
 CONRAD SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the
Alberta Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of
this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5J 4R4.
Phone: 780-427-8640.

c Return to Alberta Scholarship Programs by October 31

Personal Information
J

Z' Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current legal name) Please use upper and lower case. First Name and One Initial (current legal nam e)

Mailing Address (Include Apt, or Box Num ber) City/Town

Previous Surname
Province Postal Code Area Code Telephone Number

Birth Date Gender (circle one) Alternate Telephone Number

I
_ l ____ ____I____ ____ I____ I____ I____
day month year
M F

CITIZENSHIP (check one) Email Address:

CANADIAN CITIZEN or

PERMANENT RESIDENT (Landed Immigrant) or Have you lived in Alberta all your life? N
'---- ' Note: Include a photocopy of permanent resident card.
If no, since
Month Year

POST-SECONDARY STUDIES
Name of Educational Institution: Name of Program:

Length of your program (in years):_________ Current year enrolled in:

Office Use Only

119 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t

MO YR AUTHORIZATION AWARD KEY APP KEY

September 2013

Page 190
 Application Procedure
Complete the application form, and include the following:
• an official academic transcript,
• a one page summary of the project and its commercial potential, and
• a letter of support from at least one supervising professor or instructor, and if applicable a supporting letter by a
sponsoring company.

Declaration of Applicant

I have read and understand the instructions, and declare that:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. 1will immediately notify Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic records may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for
an award,
b. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information 1 have provided to Alberta Scholarship Programs and
for the use in research and statistical analysis and program evaluation, and
c. if 1 receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility and if 1 do not want to be identified 1 will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Date (in ink)

Information on other awards administered by Alberta Scholarship Programs can be obtained at:
Alberta Scholarship Programs
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Page 191
 Student Aid Alberta

Consent to Disclose
Personal Information to a Third Party
Instruction Sheet
Use this C o n s e n t to D is c lo s e P e rs o n a l In fo rm a tio n to a T h ird P a rty F o rm to give Innovation
and Advanced Education permission to share your personal information with a third party. If
you want to give a third party permission to take action on your behalf, complete a Power of
Attorney Form.

How to complete this form:

1. Print off the consent form. (If you are studying outside of Canada, we encourage you
to submit this form before you leave Alberta.)
2. Complete the consent form in ink with the following information:
o your full legal name (first name, middle initial, last name)
o the first 6 digits of your Social Insurance Number
o the type of information that you do not want to have disclosed
o the full legal name (first name, middle initial, last name) of the person you are
authorizing to have access to your information
o an end date on which you want your authorization to expire
3. Sign and date the consent form and make copies.
4. Submit the form to Student Aid Alberta:
o Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS
Login 3. Submit securely using e-Document Upload.
o Or mail the original to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB
T5J 4R4
5. give a copy to your authorized third party
6. keep a copy for yourself

Who do I contact for help?

Contact the Student Aid Alberta Service Centre at:
• 1-855-606-2096 toll free from anywhere in North America
• 1-855-306-2240 TTY for the hearing impaired
• 800 2 529-9242 outside North America - add the appropriate International Access Code

J u n e 2015

Page 192
 Consent to Disclose Personal
/ jf \ r lO aA T jTa n PO Box 28000 Stn Main
V H Edmonton AB T5J 4R4 Information to a Third Party
Student Aid Alberta

Your written consent authorizes Innovation and Advanced Education to disclose your personal information to a
designated individual in accordance with the Freedom of Information and Protection of Privacy Act (Alberta). If
you have any questions regarding the disclosure of information, contact the Student Aid Alberta Service Centre
toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid
Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

STUDENT’S SOCIAL INSURANCE NUMBER

(provide the first 6 digits of your Social Insurance Number only)

Print Student’s Full Legal Name (first name, middle initial, last name)

authorize Innovation and Advanced Education to disclose information, including my personal

information, contained in my student aid application and any information about the status or
consideration of my student aid application or student loan(s) (including any grants or other financial
assistance) to:

______________________________________________________ (the “Third Party”)

Print Full Legal Name (first name, middle initial, last name) of person to whom
student aid application and student loan(s) information will be disclosed

so that this individual may:

(Insert reason/purpose for which you are consenting to disclose information to this Third Party,
e.g. to manage and administer my student aid application in my absence; to assist me in my request
for review of funding provided; for the purposes of litigation; etc.)

Notwithstanding the authorization above, I do not consent to Innovation and Advanced Education
disclosing the following information to the Third Party (list any particular pieces of information that you
do not authorize the third party to obtain, e.g. do not share information regarding my disbursement
amounts or loan balance):

This authorization is valid until: You must provide an end

day month year date on which your
authorization will expire.

Signature of student

Date
J u n e 2015

Page 193
S tu d e n t A id A lb e rta Reset
SAASC: Fwd when complete to Client Resolution Unit at cru@aov.ab.ca
Service Centre
updated June 2015

CHANGE REQUEST FORM

Requested By: Date: Jan 21,2015

Student Name: ASN: App ID:

FULL/PART TIME APPLICATION PROCESSING

Locate and Process Application (L&P) Revised End

(Select Reason for L&P) date (FT only):

Freeze Application (funding has been paid)

(Select Reason for Freeze)

Re-Enter Application/Remove Freeze

(Select Reason for Re-Entry/Freeze Removal)

SCHOLARSHIPS PROCESSING

□ Changing Institution to:

□ New Student Address:

scholarship applications only

DISBURSEMENTS

Reinstate ‘cannot locate’ make sure to confirm the address is correct

| | Move up disbursement cannot move Federal Grants, ALIG or Scholarships

Type: $ Original disbursement date:

T yp e: $ Original disbursement date:

| | Grant Cheque Stop Payment or Replacement

Action Required Fund Type Amount Identifier

Select Action...

| | Lift ASL Restrict: Balance at 0 at SAASC Changes to CSL restrict info must be provided by NSLSC

p R|NT5 Reprints should only be requested if student or school cannot print from SFS Inquiry. If requesting reprint for
scholarships, provide details in Comments below

| | Letter Type: Letter #:

| 1 Tax Slip Year: \Z\COR Worksheet For manual COR only at "Required" status

| | Email MSFAAs Provide password: First name (1st letter

| 1 Regenerate MSFAAs
COMMENTS / INSTRUCTIONS
capitalized) & last 3 digits of SIN. Example Hugh123
If requesting an MSFAA or COR Worksheet be emailed, only put the student's email address in
"Comments" if it differs from the email address in SFS.
If the student requires a call back, provide as many details as possible.

Page 194
S tu d e n t A id A lb e rta Reset
SAASC: Fwd when complete to Client Resolution Unit at cru@aov.ab.ca
Service Centre
updated October 2015

CHANGE REQUEST FORM

Requested By: Date: Jan 21,2015

Student Name: ASN: App ID:

FULL/PART TIME APPLICATION PROCESSING

| j Locate and Process Application (L&P) Revised End

(Select Reason for L&P) date (FT only):

□ Freeze Application (funding has been paid)

(Select Reason for Freeze)

□ Re-Enter Application/Remove Freeze

(Select Reason for Re-Entry/Freeze Removal)

SCHOLARSHIPS: Enter either fund type number: OR Scholarship name:

I^ C h a n g in g Institution to:
Q N e w Student Address:
Only for scholarship applications
that are NOT on SFS. Rutherford
should be done online by student

DISBURSEMENTS

| | Reinstate ‘cannot locate’ make sure to confirm the address is correct

| | Move up disbursement cannot move federal grants, ALIG, Maintenance Grant or scholarships

Type: $ Original disbursement date:

T yp e: $ Original disbursement date:

| | Grant/Scholarship Cheque - Stop Payment or Replacement

Action Required Fund Type Amount Identifier

Select Action...

To initiate CSL restrict verification,enter Comments. CSL restrict info

Verify ASL Restrict: Balance shows 0
must be verified by NSLSC. PPRS will contact NSLSC directly.

RE P RINTS RePr'nts should only be requested if student or school cannot print from SFS Inquiry. If requesting a letter reprint
for scholarships, provide details in Comments.

I I Letter Type: Letter#:

I ITax Slip Year: QX COR Worksheet For manual COR only at "Required" status
I | Regenerate MSFAAs I I Email MSFAAs Provide password: First name (1st letter
capitalized) & last 3 digits of SIN. ie. John564

m M M F N K / im c t R I IP T IO M ^ Provide any additional details that may be relevant to the above action. If requesting an letter be emailed to
student, put the student's email address in "Comments" ONLY if it differs from the email address in SFS.

Page 195
David Johnston
Law Scholarship
 DAVID His Excellency, the Right Honourable David Johnston, Governor General o f Canada,
JOHNSTON has a long and distinguished legal career. In addition to terms at several different Law
LAW
Faculties, he was the Dean o f Law at the University o f Western Ontario and President
SCHOLARSHIP
of the University o f Waterloo.

This scholarship is intended to recognize one outstanding law student at each o f the
University o f Alberta and the University o f Calgary.

VALUE 2 awards o f $10,000 each will be awarded annually.

ELIGIBILITY Applicants must:

CRITERIA • be a Canadian citizen or permanent resident;
• be currently living in Alberta;
be enrolled full-time in the Faculty of Law at the University o f Alberta or the
University o f Calgary.

SELECTION Each institution will be responsible for selecting the award recipient from their
CRITERIA university. The universities will create a selection committee with appropriate
expertise. This may be the same committee as used for other institutional awards.

The committee will look at each applicant’s past accomplishments including academic
achievements, and volunteer activities. The Selection Committee will give special
consideration to applicants who are enrolled in a combined program (eg LLB/MBA
program).

APPLICATION Once the institution has made their selection they will forward the successful
PROCEDURES nominees’ applications to:
Alberta Scholarship Programs
Box 28000, Station Main
EDMONTON AB T5J 4R4 Telephone: 780-427-8640

APPLICATION
DEADLINE July 1

Page 197
Application for the David Johnston Law Scholarship N

Wc arc collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a
scholarship under the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any
questions about the collection of this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street,
Edmonton, Alberta, T5 K 2V 1 Phone 780-427-8640.

PERSONAL INFORMATION (Pleaseprint)

Social Insurance Number ______________________________________________________________

Alberta Student Number ______________________________________________________________

Surname ___________________________________________________________________________

Given Name ___________________________________________________________________________

Street Address ___________________________________________________________________________

City/Town ___________________________________________________________________________

Province __________________________ Postal Code _____________________

Telephone Number ______________________ e-mail _____________________________

Birth Date (day/month/year) ____________________________ Gender (circle) MALE or FEMALE

Citizenship (circle) CANADIAN CITIZEN or LANDED IMMIGRANT

Note: Landed Immigrants must include a photocopy of their papers. Visa students are not eligible for this award.

Do you currently live in Alberta? (circle) Yes or No

If no, please include a letter detailing when you’ve lived in Alberta.

Which post-secondary institution are you attending? _________________________________________

ATTACHMENTS
1. A resume highlighting your community activities over the last three years.
2. A related letter o f reference

Page 198
DECLARATION OF APPLICANT
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and 1 understand it is subject to audit.

I UNDERSTAND AND AGREE THAT:

a. I have answered all questions applicable to me and that all information is true and complete;
b. I propose to be a full-time student at the institution named for the period stated;
c. I will notify the office of the Alberta Scholarship Programs if I withdraw before completing one semester of
studies;
d. I authorize Advanced Education and Technology to request and receive information pertaining to my
enrolment status at my post-secondary institution;
e. I agree to allow my personal information and study plans to be released publicly if I receive a scholarship;
and,
f. 1 authorize the release and exchange of personal information by and between Advanced Education and
Technology and any federal and provincial government departments, boards or institutions to verify the
information 1 have provided to Advanced Education and Technology and for the use in research and
statistical analysis in program evaluation.

I authorize Alberta Advanced Education and Technology to release my name, institution and home town if I receive a
scholarship.

Signature o f Applicant Date

For further information contact:

Alberta Scholarship Programs
Telephone: 780-427-8640 Email: scholarships@gov.ab.ca
Or visit our website at: alis.albcrta.ca/scholarships for information on 450
different awards, scholarships and bursaries available to Alberta students.

Page 199
 Appeal Application for
De-Designation
S tu d e n t A id A lb e r ta

APPEAL PROCESS
• An educational institution can appeal within 60 days from the notice of their de-designation.
• The educational institution owner or designated representative can complete the appeal and mail
to: (or fax to 780-422-4516)

Innovation and Advanced Education

Executive Director, Student Aid
9th Floor, Sterling Place
9940 106 Street
Edmonton AB T5K 2V1

• The Executive Director will review the appeal. A meeting with the owner or designated
representative may be scheduled if further clarification is required.
• The Executive Director will make a decision within 30 days of receiving the appeal and will notify
the owner or designated representative in writing.

EDUCATIONAL INSTITUTION DETAILS

Address

Phone Number

Fax Number

More information and signature(s)

required on the reverse side.
June 2014

Page 200
DETAILS OF APPEAL (attach additional pages if required)

1. Did you develop a Loan Repayment Strategy in recent years? Q Yes Q No

If yes, please attach strategy.
If yes, when were the strategies implemented?_________________________

2. Have you monitored the results of the strategy? Q ] Yes No

Is yes, please provide findings.

3. P ro vid e a ny o th e r a d d itio n a l m a te ria l o r re a so n s th a t s u p p o rts w h y you feel y o u r in stitu tio n sh ou ld not

be d e -d e s ig n a te d .

NAME(S) and SIGNATURE(S)

Owner or Designated Representative name (PRINT) Owner or Designated Representative (PRINT)

Signature of Owner or Designated Representative Signature of Owner or Designated Representative

Date Date

June 2014

Page 201
y$dbe*bcyj* Disability Grant Summary
Student Aid Alberta

NAME:______________________________________ Social Insurance Number:

See the DG letter(s) for complete details.

Receipt or
Am ount Am ount
Academ ic Period Date Cheque
Awarded Received
(R or C) O/P Initials

Page 202
 Dr. Gary McPherson
Leadership Scholarship

Page 203
 Dr. Gary McPherson Leadership Scholarship
Dr. Gary McPherson was a renowned advocate for people with disabilities. He devoted himself to inspiring leadership and
bringing out the best in everyone. He was a member of the Order of Canada, the Alberta Order of Excellence and both the
Edmonton and Alberta Sports Halls of Fame.

This scholarship recognizes students who have demonstrated outstanding leadership, especially in the area of disability,
and/or initiative to improve the conditions and lives of others.

Award Value

100 awards of $2,000 each will be awarded annually.

Eligibility Criteria
Applicants must:
• be a Canadian Citizen or Permanent Resident,
• be currently living in Alberta,
• be enrolled full-time in a post-secondary program: undergraduate, professional, graduate, apprenticeship, diploma
or certificate program at a designated Alberta institution in the year of nomination, and
• have shown outstanding leadership, especially in the area of disability, and/or initiative to improve the lives of
other people while attending a post-secondary institution in Alberta.

Selection Procedure

Each institution will establish a selection committee with appropriate expertise. The Student Awards Office my also set an
earlier application deadline. This committee may be the same as used for other institutional awards. The committee will
consider the role and contribution each applicant has made at their school. The selection committee may also take into
consideration marks, financial need, and other activities as secondary selection criteria.

Application Procedure

Include with your completed application:

• a resume highlighting your leadership involvement and other activities related to improving the lives of other
people,
• a related letter of reference, and
• an essay of up to a maximum of 1,000 words - please refer to page 4 of the application for details.

Submit your completed application form to the Student Awards Office at your educational institution.
Please note that the application deadline of February 1st is the deadline for institutions to submit the
applications of the successful candidates to Alberta Scholarship Programs. Applicants are advised to
contact the Student Awards Office early in the fall to inquire as to the selection process and the
application deadline.

Submission Deadline for educational institutions is: February 1

 Dr. Gary McPherson Leadership Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Return your completed application to the Student Awards Office at your educational institution.

Personal Information
Alberta Student Number (go to www.education.ab.ca to find your ASN or to obtain one) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province CountnI______________________ Postal Code Area Code Telephone Number

Gender (circle one) Birthdate__________________ Email Address

day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
Do you live in Alberta?
If no, please include a letter indicating where you arc currently living.

POST-SECONDARY STUDIES
Name of Educational Institution

Name of Program: Entry Date of Program

m onth year

Revised: April 2014

Page 205
 Dr. Gary McPherson Leadership Scholarship
Biography

After reading the biography of Dr. Gary McPherson please attach an essay o f up to a maximum o f 1,000
words using examples of how you have shown leadership, especially in the area of disability, and/or initiative
to improve the lives of others. The essay should be typed, double-spaced and use a font size no smaller than
a sizelO.

Dr. Gary McPherson Biography

Dr. Gary McPherson was an extraordinary Albertan who sought to improve the conditions and lives of
people through his outstanding leadership ability. Despite being paralyzed due to polio, McPherson was a
sports enthusiast throughout his life and helped to transform wheelchair sports into a worldwide sporting
movement known as the Paralympics.

McPherson was also a leader and advocate for the disabled community serving as Chair o f the Premier's
Council on the Status o f Persons with Disabilities and Vice-Chair o f the Alberta Paraplegic Foundation.
Gary received significant recognition and awards for his achievements including the prestigious Order of
Canada, the Queen's Jubilee Medal and the Alberta Order o f Excellence.

Above all, Gary dedicated his life to his family and to activities that promoted community development
and support for young people. Gary passed away on Saturday, May 8, 2010.

Declaration of Applicant

1 HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time
studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT:
a. personal information pertaining to my post-secondary academic enrollment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the purpose of
determining my eligibility for a scholarship;
b. personal information may be released and exchanged by and between Alberta Scholarship Programs and any
provincial government departments, boards or institutions to verify the information I have provided to Alberta
Scholarship Programs, and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however this is not a criterion for eligibility, and if I do not want to be identified I will contact
Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Dr. Martha Kostuch
Consensus Building
Legacy Award

Government of Alberta ■
A d v a n c e d E d u c a tio n a n d T e c h n o lo g y
Page 207
 Dr. Martha Kostuch Consensus Building Legacy Award
Dr. Martha Kostuch was a recognized advocate on environmental issues, who built her reputation by bringing various stakeholders
together to find collaborative solutions to the environmental issues facing Alberta.

This award is designed to assist individuals in non-government organizations who wish to expand and enhance their education,
training, knowledge and use of consensus-based decision-making processes.

Up to $15,000 is available annually. Recipients will be reimbursed for direct cost of educational expenses.

Eligibility Criteria

Applicants must:
• be a Canadian Citizen or permanent resident of Canada, and a resident of Alberta, and
• be enrolled or planning to enroll in a course through Alberta Arbitration and Mediation Society Consensus-Building
Certificate Program.
Awards are not retroactive; you cannot apply for a course that has been completed prior to the application deadline.
Awards are not intended to duplicate other funding.

Selection Procedure

A selection committee comprised of one member from Alberta Environment, one member from Alberta Advanced Education and
Technology, and one public member, will choose recipients and the value of their awards.

Preference will be given to applicants who:

• are members of an environmental not-for-profit organization,

• are active participants in environmental/resource management consensus-based initiatives,
• have demonstrated openness to multi-stakeholder dialogue, and
• have been an Alberta resident for a minimum of one year.
Note: Applications from other not-for-profit non-governmental organizations will be considered.

Application Procedure

Submit with the application:

• a one-page summary (maximum 1000 words) outlining your interests and activities and how you will use
your consensus-building training,
• a letter of endorsement by a non-government organization, and
• a curriculum vitae/resume highlighting your involvement with environmental not-for-profit organizations.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB - T5K 2V1

Phone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

Application Deadline is November 30.

Page 208
 Dr. Martha Kostuch Consensus Building Legacy Award

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under
the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the
collection of this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta,'T5K 2V1
Phone 780-427-8640.

Personal Information

Surname Social Insurance Number

Given Name and Middle Initial

Mailing Address (include Apt. or Box Number) City/Town

Province Postal Code Area Code Telephone Number

CITIZENSHIP (check one) ALBERTA RESIDENCY

CANADIAN CITIZEN OR N Have you lived in Alberta all your life? (circle one)
PERMANENT RESIDENT (Landed Immigrant) If no, since
------ Note: Include a photocopy of permanent resident card or immigration long form.
Visa students are not eligible. month year

Gender (circle one) Birthdate (D a y, M onth, Y e a r) Email Address

M F
i I i ___I___ I___ I___

Application deadline is November 30.

Office Use Only

April 2015

Page 209
 Attachments:
You must attach the following to your application:

1. A resume highlighting your involvement in

enrironmental not-for-profit organizations.,
2. A letter of endorsement by a non-govemment
organization,
3. A one-page summary (maximum 1000 words) outlining
your interests and activities and how you will use your
consensus-building training.

Notification of results may be expected within eight weeks after submitting an application.

Declaration of Applicant

1 HAVE READ THE INSTRUCTIONS, AND DECLARE THAT:

a. all information is true and complete and I understand it is subject to audit;

b. 1 agree to fulfill the commitments of any award made pursuant to this application;
c. 1 agree to allow my name and study plans to be released publicly if I receive this award; and
d. I authorize the release and exchange of my personal information by and between Innovation and Advanced Education
and any federal and provincial government departments or institutions to verify the information I have
provided to Alberta Innovation and Advanced Education and for the use in research and statistical analysis or in
program evaluation and program promotion.

I authorize Innovation and Advanced Education to release my name, award and home town if I receive an award.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 210
Dr. Robert and Anna
Shaw Citizenship
Scholarship

Government
of Alberta ■
Page 211
 Dr. Robert and Anna Shaw Citizenship Scholarship
This scholarship is named in honour of Dr. Robert and Anna Shaw, pioneers in the Sexsmith area. Dr. and Mrs. Shaw are
remembered for their many volunteer commitments to the community including serving on the local Board of Trade, Town Council,
School Board, teaching Sunday School and substituting for the minister. They were both willing to provide whatever assistance was
needed to help people with their problems.

The Dr. Robert and Anna Shaw Citizenship scholarship recognizes the academic and leadership accomplishments of students
graduating from Sexsmith Secondary School entering the fields of agriculture, engineering, fine arts or the trades.

Three awards of $500.

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Sexsmith Secondary School after September 1, 1996,
c. plan to enroll or be enrolled full-time in a post-secondary program related to agriculture, engineering, fine arts or the trades,
d. demonstrate a high academic standing in their Grade 12 year, and
e. demonstrate outstanding qualities in the areas of leadership, community spirit, involvement in extra-curricular activities
and a commitment to place the welfare of others above their own needs.

Selection Procedure
The selection committee will select recipients on the basis of demonstrated leadership, community involvement, participation in
extra-curricula activites.

Application Procedure
Submit completed application form and a summary of your leadership activities, community involvement, and extra-curricular
activities that demonstrate your community spirit and concern for others.

Students will be notified of the status of their application in September and the awards are issued in November after Alberta
Scholarship Programs confirms full-time enrolment of the successful candidates.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline: June 1

Page 212
 Dr. Robert and Anna Shaw Citizenship Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required fo r processing)

Last Name (c u rre n t fu ll legal nam e) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll legal nam e)

Mailing Address (In c lu d e A p t, o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email

M <jay | myith | ^ yepr ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students arc not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____I____ ____i____ i____ i____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? | | Yes, what year__________ | | No

Are you a student at Sexsmith Secondary School? N

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month 1 year monthl year
____1____ ____ 1____ 1____ 1____
Institution City Length of Program Year of Program

ED 2nd 3rd 4th

Office Use Only

60 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Disbursement

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: April 2015

Page 213
 In two pages or less, please include a summary of your leadership activities,
community involvement, and extra-curricular activities that demonstrate your
community spirit and concern for others. You may include letters of
references to support your application.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by
and between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility
for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Advanced Education and Technology
and any provincial government departments, boards or institutions to verify the information I have provided to Alberta
Advanced Education and Technology, and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and hometown may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 214
Dr. Robert Norman Shaw
Scholarship

Government
of Alberta ■
Page 215
 Dr. Robert Norman Shaw Scholarship
This scholarship is named in honour of Dr. Robert Norman Shaw, a pioneer in the Sexsmith area. Dr. Shaw is remembered for his
contributions to the community as a doctor, engineer, veterinarian and coroner..

The Dr. Robert Norman Shaw scholarship recognizes and rewards the exceptional academic achievement of a student graduating
from Sexsmith Secondary School and who is entering post-secondary studies in a health related field.

One award of $1,500.

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Sexsmith Secondary School after September 1, 1996,
c. plan to enroll or be enrolled full-time in a post-secondary program related to health, and
d. demonstrate a high academic standing in Grade 12.

Selection Procedure
Recipients will be selected based on the highest average marks obtained in five eligible Grade 12 courses:
One of: English 30, 30-1 or 30-2, or Francais 30, or 30-2
At least four the following Grade 12 courses:
Pure Mathematics 30 Applied Mathematics 30
Science 30 Biology 30
Chemistry 30 Physics 30
Social Studies 30, 30-1 or 30-2 a language other then one used above

Application Procedure

Submit completed application form to Alberta Scholarship Programs.

Students will be notified of the status of their application in September and the awards are issued in November after Alberta
Scholarship Programs confirms full-time enrolment of the successful candidates.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K.2V1

Phone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline: June 1

Page 216
 Dr. Robert Norman Shaw Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/To\vn

Previous Surname
Province Country Postal Code Area Code felephone Number

G e n d e r (circle one) Date of Birth Email

M F day I month I year
L_ I I
____ __ ____ I____ ____ I__ _ L ____I____

CITIZENSHIP (check one)

CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____ I____ ____ I____ I____ I____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? |___| Yes, what year
□ No

Are you a student at Sexsmith Secondary School? N

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academ c End L)ate

month I year month I year
____I____ ____ I____ I____ I____
Institution City Length of Program Year of Program
1st 2nd 3rd 4th

Page 217
 Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Advanced Education and Technology and
any provincial government departments, boards or institutions to verify the information I have provided to Alberta Advanced
Education and Technology, and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and hometown may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if 1 do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
If your institution code is not listed here, see list of Publicly Funded Institutions.

University of Alberta.................... ...2201
University of Calgary................... ...2202
University of Lethbridge.............. ...2203
NAIT............................................. ...2221
SAIT............................................. ...2222
Alberta College of Art & Design... ...5110
Ambrose University..................... ...9041
Athabasca University.................... ...2204
Bow Valley College...................... ...2218
Concordia University College (AB)..2246
Devry Institute of Technology...... ....2040
Grande Prairie Regional College... ....2241
Grant MacEwan University.......... ....2247
Keyano College............................ ....2230
Kings University College............. ....2255
Lakeland College.......................... ....2225
Lethbridge College....................... ....2220
Medicine Hat College................... ....2242
Mount Royal University........ ......... 2243
Northern Lakes College......... .........2020
Norquest College................... ......... 2226
Olds College.......................... ......... 2224
Portage College...................... ......... 2219
Red Deer College................... .........2244
St. Mary’s ............................... .........5661

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 218
Earl and Countess of
Wessex
World Championships in
Athletics Scholarship

Page 219
 EARL and COUNTESS of WESSEX - WORLD CHAMPIONSHIPS in
ATHLETICS SCHOLARSHIP

The Earl and Countess of Wessex - Edmonton 2001 World Championships in Athletics Scholarship was established by the
Government of Alberta to commemorate the visit of Their Royal Highnesses The Earl and Countess of Wessex to the 8th
International Association of Athletic Federations (IAAF) World Championships in Athletics.

This scholarship recognizes the top male and top female Alberta students who have excelled in track and field, have a strong
academic record and plan to continue their studies at the post-secondary level in Alberta.

Two awards of $3,000 are awarded yearly.

Eligibility Criteria

Applicants must
a. be a Canadian citizen or permanent resident,
b. be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the qualifying year,
c. plan on entering full-time post-secondary studies at the University of Alberta, the University of Calgary or the University
of Lethbridge and must join the Track and Field team at that institution within one year,
d. have completed Grade 12 in Alberta in the same year that they apply for the scholarship, and
e. have met the entrance requirements to be accepted at either institution.

Selection Procedures

Selection will be based on a student’s placement in provincial and national championships, Alberta Athlete Development Program
(AADP) standards, best performances, Mercier score and a written recommendation from the applicant’s coach. Recipients will be
chosen by a selection committee with representation from Athletics Alberta and from each of the varsity track and field programs in
Alberta.

Application Procedures

Applications are also available from high school counsellors. Applicants will be notified of the result of their application in
December. The award will be issued in January after Alberta Scholarship Programs confirms the recipients’ full-time enrolment.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.gov.ab.ca/scholarships

ALBERTA SCHOLARSHIP PROGRAMS

Alberta Scholarship Programs including the Alberta Heritage Scholarship fund and the Achievement Scholarship Program, were
designed to stimulate the pursuit of excellence by rewarding outstanding achievement.

Application Deadline is October 1

Page 220
 EARL and COUNTESS of WESSEX - EDMONTON 2001 WORLD
CHAMPIONSHIPS in ATHLETICS SCHOLARSHIP
Wc arc collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor - 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
You may use the Learner Registry at w w w .e d u c a tio n .g o v .a b .ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number ( r e q u i r e d f o r p r o c e s s in g ) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt, or Box Number) Citv/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

G e n d e r (circle one) Birth date Email Address

M J ____I____L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or | PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school
N N
Have you lived in Alberta all your life?
IF YOU ANSWERED “NO” TO EITHER OF THESE QUESTIONS PLEASE
N Since INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
_L J ____I____L
month year

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Location Start Date of Program

_L J ____I____L
month year

Institution Codes:
The University of Alberta 2201 The University of Calgary 2202 The University of Lethbridge 2203

Office Use Only

Revised: May 2013

Page 221
HIGH SCHOOL INFORMATION
Name of high school you are you attending for Grade 12:
Year you will graduate from high school?

ATHLETIC INFORMATION
Sport _________________________________________ Athletics Alberta registration number __________________________
Will you be joining the Track and Field Team at the post-secondary institution you will be attending? (circle) Yes or No

Name of coach who will be completing the attached reference form

Attach a list of your Track and Field accomplishments to date: name of event, placing, and any other relevant details. State
your personal best performances and provincial high school championships placing for your best event(s).

Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from
full-time studies before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged
by and between Alberta Scholarship Programs for the purpose of determining my eligibility for a
scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may be released
and exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the information
I have provided to Alberta Scholarship Programs, and for the use in research and statistical analysis in
program evaluation.
I UNDERSTAND AND AGREE THAT:

iff receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

HAVE YOU ANSWERED ALL QUESTIONS?

Your application may be delayed if information is missing.

Page 222
 Reference Form

EARL and COUNTESS of WESSEX - EDMONTON 2001 WORLD CHAMPIONSHIPS in

ATHLETICS SCHOLARSHIP

NOTE TO COACH

Since there is a large number o f qualified candidates competing for a limited number o f awards, we would like
to ensure the most deserving individuals are identified; and appreciate your cooperation in rating this
candidate.

You may submit a typed letter commenting on the areas listed below or complete the form on the next page.
If submitting a separate letter, please indicate your professional relationship to the candidate and ensure that
you clearly state the name o f the applicant and the name o f the award.

Your comments should be as precise as possible. For example, state a comparison group, its size, and the
applicant’s rank in that group. Your appraisal should include an evaluation o f the candidate in the following
areas:
general athletic skills
skills specific to their sport
dedication, and
general scholastic performance

Your prompt attention to the candidate’s request to provide this reference is important. Without a reference,
the candidate will not be considered for this scholarship. Your comments are received in confidence.

Reference letters must be returned by October 1 to:

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Page 223
 EARL and COUNTESS of WESSEX - EDMONTON 2001 WORLD CHAMPIONSHIPS in
ATHLETICS SCHOLARSHIP

Reference for: _______________________________________________________________________

Name of Applicant

NOTE TO COACH: Please print legibly in dark ink. Our office will be photocopying this form,

a) Briefly define your professional relationship to the candidate (including how long you have known the applicant).

b) Assessment (should extra space be required please attach another page).

General athletic skills:

Skills specific to their sport:

Dedication:

General scholastic performance:

General comments, including placing at events (use additional pages if required).

Name of Coach Number of years coaching

Current School Number of athletes coached

Signature of Coach Date Business telephone number

Page 224
 S tudent A id Alberta
Memorandum
FROM: Launa Lebeau DATE: August 5, 2015
Director, Student Services Branch TELEPHONE: 780-427-9820
Apprenticeship and Student Aid REFERENCE: 475-919-148

TO: Maggie DesLauriers

Executive Director
Innovation and Advanced Education
Apprenticeship and Student Aid

SUBJECT

INSTITUTION

REASON FOR REASSESSMENT

PERIOD(S) OF REASSESSED

AMOUNT OF OVERPAYMENT

CIRCUMSTANCES:

REASON FOR APPEAL

SUMMARY PREPARED BY

R ecom m endation:

Reviewed & Recommended by:

Lindsay Leong, Auditor, Program Compliance & Investigations Date

Launa Lebeau, Director, Student Services Branch Date

— Buyi 225
(Student Name) Level II Appeal Page 1
 — Puyi 226
(Student Name) Level II Appeal Page 2
Government of Alberta ■
Student Aid Alberta
Memorandum
FROM: Your Name OUR FILE REFRENCE:
Program Compliance & Investigations

TO: Hal Marcellin DATE:

Acting Manager PHONE:
Program Compliance & Investigations

REQUEST TO EXTEND THE PERIOD OF APPEAL

SUBJECT

REASON FOR REASSESSMENT

PERIOD(S) REASSESSED

AMOUNT OF OVER-AWARD

CIRCUMSTANCES: (O riginal appeal d e a d lin e -)

RECOMMENDATION:

REASON(S) FOR THE REQUEST TO

EXTEND THE APPEAL PERIOD

PREPARED BY

□ THE STUDENT REQUEST FOR AN EXTENSION OF THEIR APPEAL PERIOD IS - DECLINED

□ THE STUDENT REQUEST FOR AN EXTENSION OF THEIR APPEAL PERIOD IS - APPROVED

Amended Appeal Deadline:

Conditions of Extension, if any:

H al M a rc e llin , A c tin g M a n a g e r, P ro g ra m C o m p lia n c e & In v e stig a tio n s D ate

Page 227
 Fellowship for
Full-Time Studies in
French
 FELLOWSHIP FOR FULL-TIME STUDIES IN FRENCH

Funded by the federal department of Canadian Heritage and administered by Alberta Innovation and Advanced Education,the
fellowship is designed to assist Alberta students pursuing post-secondary studies taught in French.

Eligibility Criteria

Applicants must:
• be either a Canadian Citizen or a permanent resident (visa students are not eligible),
• be an Alberta resident and to be considered an Alberta resident one of the following conditions must
apply: one parent must currently be residing in Alberta, or Alberta is the last place you have lived for
twelve (12) consecutive months before being a full-time student, or you are married to an Alberta resident
before the start of your qualifying year of study,
• be registered full-time in a post-secondary program - full-time is defined as being enrolled in a
minimum of a 60% course load, and
• be taking a minimum of three courses per semester in which the course content and the language of
instruction are in French.

Types of Fellowships

The Fellowship has a minimum value of $500 per semester. A student who meets the course requirement for two semesters will
receive a full fellowship of $1,000. Depending on funds available from the federal department of Canadian Heritage an
additional fellowship - the Roger Mahe Memorial Award may be awarded. Awards are valued at $500 per semester, and
recipients are selected based on academic achievement during the previous year of post-secondary study. In previous years the
GPA on a 4.0 scale has been in the range of 3.7 and above. The number of awards offered is dependent on the amount of
funding available from Canadian Heritage.

Application Procedure*

Include with your application:

* proof of Canadian citizenship: either a photocopy of Canadian birth certificate, passport, permanent resident card or
immigration long fonn.
* an official academic transcript if you attended post-secondary studies in the previous academic year. Students entering the
first year of a post-secondary program directly from high school do not need to send a high school transcript.

Note: You must apply each year for the fellowship as it is not automatically renewed.
Even if you have not registered in your courses, submit your application. Confirmation of your courses are verified by
Alberta Scholarship Programs in January for both the fall and winter semesters. The award is usually paid in March.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

A p p lic a tio n D e a d lin e : N O V E M B E R 15 fo r F a ll a n d /o r W in te r Semesters

 FELLOWSHIP FOR FULL-TIME STUDIES IN FRENCH

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship and to administer the
Alberta Scholarship Programs. If you have any questions about the collection of this information, please contact Alberta Scholarship
Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Application must include proof of citizenship: either a photocopy of Canadian birth certificate, passport, or permanent resident card.
You may use the Learner Registry at w w w .e d u c atio n .g o v .ab .ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (re q u ire d fo r p roce ssin g)

Last Name (c u rre n t legal nam e) Please use u pp e r and lo w e r case

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Province Postal Code Area Code Telephone Number

Gender Date of Birth Email Address

M F i I i I i i i
day month year
Previous Surname (if anv)

CITIZENSHIP (check one)

□ CANADIAN CITIZEN OR
Are you (check one)
□ PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy o f permanent resident card or immigration long form. Visa students are not eligible.

□ FRANCOPHONE (One parent has French as a first language) Of

□ ANGLOPHONE (Neither parent has French as a first language)
ALBERTA RESIDENCY
Y N If no, since * If your parents do not currently reside in Alberta AND you have not lived in
l____ l____ l____ l____ Alberta all your life, please include a letter explaining the time spent in
month year
Alberta as as a non-full-time student.
Do vour parents currentlv live in Alberta?
Y N

Office Use Only

Revised: March 2014

Page 230
 Education Information

Name of post-secondary institution:

Name of program: Is your program taught in French?

Year enrolled in: (check one) ___ ___ Name of campus:

1st | 12nd | 13rd | 14th | | Other

Dates you will be attending and taking a minimum of 3 courses taught in French:
From To
___I__ ___ I____I____I___ __ l__ __ l___ I___I__
month year month year

Indicate the semester(s): (check one)

Fall Semester Winter Semester
□ Both Semesters

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw
from full-time studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT
a. my personal information pertaining to my post-secondary academic record and enrolment
status may be released and exchanged by and between Alberta Scholarship Programs and the
educational institution for the purpose of determining my eligibility for a scholarship;
b. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Scholarship Programs and for the use in research and
statistical analysis in program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Remember to enclose proof of citizenship either a photocopy of birth certificate, passport, or permanent resident
card. Attach an official transcript if you attended post-secondary studies the pevious academic year.

A p p lic a tio n D e a dline : N O V E M B E R 15 fo r F a ll a n d /o r W in te r Semesters

Page 231
 Student Aid Alberta

Fellowship for Full-time

Studies in French

Page 232
 Fellowship for Full-time Studies in French
Funded by the federal department of Canadian Heritage and administered by Alberta Advanced Education, the fellowship is designed
to assist Alberta students pursuing post-secondary studies taught in French.

Eligibility Criteria
Applicants must:
• be either a Canadian Citizen or a permanent resident (visa students are not eligible),
• be an Alberta resident and to be considered an Alberta resident one of the following conditions must
apply: one parent must currently be residing in Alberta, or Alberta is the last place you have lived for
twelve (12) consecutive months before being a full-time student, or you are married to an Alberta resident
before the start of your qualifying year of study,
• be registered full-time in a post-secondary program - full-time is defined as being enrolled in a
minimum of a 60% course load, and
• be taking a minimum of three courses per semester in which the course content and the language of
instruction are in French.

Types of Fellowships
The Fellowship has a minimum value of $500 per semester. A student who meets the course requirement for two semesters will
receive a full fellowship of SI,000. Depending on funds available from the federal department of Canadian Heritage an
additional fellowship - the Roger Mahe Memorial Award may be awarded.

Awards are valued at $500 per semester, and recipients are selected based on academic achievement during the previous year of
post-secondary study. In previous years the GPA on a 4.0 scale has been in the range of 3.7 and above. The number of awards
offered is dependent on the amount of funding available from Canadian Heritage.

Application Procedure
Include with your application:
* proof of Canadian citizenship: either a photocopy of Canadian birth certificate, passport, permanent resident card or
immigration long form.
* an official academic transcript if you attended post-secondary studies in the previous academic year. Students entering the
first year of a post-secondary program directly from high school do not need to send a high school transcript.

Note: You must apply each year for the fellowship as it is not automatically renewed.
Even if you have not registered in your courses, submit your application. Confirmation of your courses are verified by
Student Aid Alberta in January for both the fall and winter semesters. The award is usually paid in March.

Faxed applications are not accepted.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Application Deadline: November 20 for Fall/Winter Semesters

Page 233
 Fellowship for Full-time Studies in French

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
Application must include proof of citizenship: either a photocopy of Canadian birth certificate, passport, or permanent resident card.
You may use the Learner Registry at e d u c a t i o n . g o v . a b . c a to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current legal nam e) Please use upper and lower case. First Name and One Initial (current legal name)

Mailing Address (Include Apt, or Box Num ber) City/Town

Province Postal Code Area Code Telephone Number

Gender Date of Birth Email

day month year

Previous Surname (if any)

CITIZENSHIP (check one)

] CANADIAN CITIZEN OR Q PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
Are you (check one)
|FRANCOPHONE (One parent has French as a first language) ANGLOPHONE (Neither parent has French as a first language)

*ALBERTA RESIDENCY
Have you lived in Alberta all your life?
Y N If no, since If A lberta AND y o u have n o t
y o u r pa r en t s d o n o t c u r r e n t l y r e s id e in
__ I__ __ I___I___I__ l iv e d in A lberta a l l y o u r l if e , p l e a se in c l u d e a l e t t e r e x p l a in in g t h e
month year
TIME SPENT IN ALBERTA AS AS A NON-FULL-TIME STUDENT.
Do your parents currently live in Alberta?
YI N .

Office Use Only

Revised: Dec 2015

Page 234
 Education Information

Name of post-secondary institution:

Name of program: Is your program taught in French?

Y N

Year enrolled in: (cheek one) Name of campus:

1st | 12nd | 13rd | 14th | | Other

Dates you will be attending and taking a minimum of 3 courses taught in French:
From To
___1__ __ 1___1___1__ __ 1__ __ 1___1___1__

Indicate the semester(s): (check one)

Fall Semester | |Winter Semester Both Semesters

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies
before completing one semester of studies.
I UNDERSTAND AND AGREE THAT
a. my personal information pertaining to my post-secondary academic record and enrolment status
may be released and exchanged by and between Student Aid Alberta and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information may be released and exchanged by and between Student Aid Alberta and any
provincial government departments, boards or institutions to verify the information I have provided to
Student Aid Alberta and for the use in research and statistical analysis in program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if 1 do not want to be identified, I will contact
Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Remember to Enclose:

• P ro o f o f C itiz e n s h ip : either a photocopy of birth certificate, passport, or permanent resident card.

• A tta c h an O ffic ia l T ra n s c rip t: if you attended post-secondary studies in the previous academic year.

Application Deadline: November 20 for fall/winter semesters

Page 235
 Innovation and
jm Advanced Education

STATUTORY DECLARATION
This declaration should be completed in the handwriting of the claimant.
I,_________________________________________________ of _______________________________________________
(Full Name of Payee - please print) (address)

_______________________________________________________________________________ do solemnly declare:

I. That I am the payee named in the original cheque numbered ___________ d a te d ____ -__-__for the amount

of $_____ issued by HER Majesty the Queen represented by the Provincial Treasurer, in favour of Alberta
Innovation & Advanced Education
II. That I have not benefited either directly or indirectly by the proceeds of the said cheque.

III. That the following are two specimens of my signature: ____________________________________

(Signature)

(Signature)

IV. That the answers to the questions below are given by me and are true to the best of my knowledge,
information and belief.

(1) Have you examined the cheque or a Photostat copy of the cheque showing the endorsement of your

name? □ Yes □ No

(2) Did you receive the cheque or did you ever see it? □ Yes □ No

(3) Did you endorse the cheque? □ Yes □ No

(4) Was the endorsement of your name on the cheque made with your consent or by agreement or
understanding with anyone? □ Yes □ No

(5) Do you know who received the cheque or endorsed your name thereon or who received any benefit in

money or credit or anything of value from the cashing of the cheque? □ Yes □ No

If yes, what is the name of the p e rs o n ? _______________________________________________________

(6) Are you known in the place where the cheque was cashed? □ Yes □ No

(7) What was your mailing address on the date the cheque was due to arrive?________________________

(8) What are the names and addresses, and relationship to you, if any, of the persons who resided with you

at the time, at the address described in number (7)?______________________________________________

(9) Where and with whom did the Postal employee leave your mail? Also, state your forwarding address, if

one was u s e d :______________________________________________________________________________

Page 1 of 2 Continued on reverse side

Page 236
 STATUTORY DECLARATION - continued from Page 1

10) Do you have any reason to believe that the cheque was endorsed or that the proceeds were received by
any member of your family, by any associate or by any other person whose name is listed in the answer

to number (8 )? ______________________________________________________________________________

(11) Was the loss, non-receipt, or theft of the cheque caused by any fault or negligence of your own?

□ Yes □ No

(12) Where did you usually cash your cheque at the time other above described cheque was cashed?______

(13) Give other facts known to you regarding the negotiation of the cheque.

(14) I have asked Alberta Innovation and Advanced Education to issue a new cheque to replace the above

cheque.

(15) If my request is approved, I understand that if I cash or use the above cheque for payment, I may be

charged with a criminal offence.

And I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force
and effect as if made under oath and virtue of the C a n a d a E v id e n c e A c t.

Declared before me at Province of

(city, town, or village)
this dav of A.D. 20
(date) (month)

(Signature of Justice of the Peace, Commissioner of Oaths, Notary Public, etc.) Signature of Payee)

PRINT LEGIBLY OR STAMP HERE

Appointment Expires 20

(To be used when the endorsement on cheque is alleged to be a forgery.)

Page 2 of 2

Page 237
 Form H-CDC
y & lk e r b t m Government Application for Financial Hardship
Crown Debt Collections
PO Box 11416, Edmonton AB T5J 3K6
Telephone: 780-427-3244 Fax: 780-644-2132
Service Alberta, Crown Debt Collections is responsible for the collection of overdue receivables owing to the Crown, including amounts
owing under the Student Financial Assistance Act (Alberta). Personal information is collected under the authority of section 33(c) of the
Freedom of Information and Protection of Privacy Act (the Act) and will be used to assess the Applicant's eligibility for loan relief based on
financial hardship, collection and enforcement related to the monies owing and for administration (including research, statistical analysis and
evaluations) under the Student Financial Assistance Act (Alberta) and the Crown Debt Collection program. The use and disclosure of
personal information is managed in accordance with the Act. Enquiries regarding the collection, use or disclosure of this information may be
directed to the Manager, Crown Debt Collections, PO Box 11416, Edmonton, Alberta, T5J 3K6 or 780-427-3244 or Alberta toll free at 310-
0000-780-427-3244.

Debt Information Account # - d o n o t c o m p le te (o ffic e u s e o n ly )

Alberta Student Loan Balance Owing: Grant Overpayment Balance Owing:

$ $
Personal Information
Name: (surname) (first) (middle)

Address: (street, FtFt#, PO Box) (town/city) (province) (postal code)

Social Insurance Number Date of Birth (yy/mm/dd) Marital Status: Q Sing|e Q Married
□ Divorced □ Common law**

Spouse's/Partner's Name: (surname) (first) (middle) Date of Birth (yy/mm/dd)

Home Phone Number: Number of Dependent children and Ages: (Dependent children are those children who are living
with you and for whom you and/or your spouse/partner are legally responsible.)

Residential Information
Landlord’s Name: Monthly Rent:

$
Landlord’s Address:

Name of Mortgage Company (if you are a homeowner): Monthly Mortgage Payment (if you
are a homeowner): $
Address of Mortgage Company (if you are a homeowner):

Mortgage Balance (if you are a homeowner): Approximate Property Value (if you a re a h o m e o w n e r): Equity (if you a re a hom eow ner):

$ $ $
Tax Information (You and your spouse/partner must submit a copy of your most recent Notice of Assessment from
Canada Revenue Agency to substantiate the Tax Information entered below.)
Enter your Total Income from Line 150 of your Enter your spouse's/partner's Total Income from Line 150 of your
current Income Tax Return: spouse's/partner’s current Income Tax Return:

s s

Page 1 October 2015

Page 238
 This person(s) will be contacted to obtain your new address or phone number if unable to contact you
Contacts using the information you provided.

Relatives/Friends: Telephone Number:

Relatives/Friends: Telephone Number:

Bankruptcy Information

Have you ever declared bankruptcy? □ Yes □ No If yes, provide: Name of Trustee Discharge Date

Family Income
Your Place of Employment or Self-Employment: Position: Monthly Salary (net):
$
Address of Employment: Business Phone Number:

Spouse's/Partner’s Place of Employment or Self-Employment: Position: Monthly Salary (net):

$
Spouse’s/Partner's Address of Employment: Business Phone Number:

Family Income - other sources Amount

Child Support $

Rental Income $

Old Age Security $

AISH $

Canada Pension Plan $

Universal Child Care Benefits $

Disability Pension $

W orker’s Compensation $

Income Support (Alberta Works) $

Band Funding $

Child Tax Credit Benefit $

Other(s) $

TOTAL INCOME $

Page 2 October 2015

Page 239
Family Monthly Expenses (y o u m a y Description Monthly Outstanding
b e a s k e d to s u b m it p r o o f o f e x tr a o r d in a r y
expenses)
Payment Balance

Student Aid (include Canada $ $

and Alberta student aid)

Bank Loan $ $
Finance Company $ $
Credit Cards $ $
Rent/Mortgage/T axes $ $
Insurance $ $
Utilities $ $
Telephone $ $
Food $ $
Child Care/Support $ $
Transportation $ $
Uninsured Medical Expenses $ $
Other (e.g. clothing, personal care, etc) $ $

TOTAL EXPENSES $ $

Assets
Vehicles Owned/Leased (indicate if by Applicant or Make: Model and year: Vehicle Equity:
by spouse/partner: $
Other Assets (specify type of asset, value, and date of purchase, e.g. stocks, bonds, RRSPs, GICs, etc. and whether owned by Applicant or
spouse/partner):

Banking Information of Applicant and Spouse/Partner

Name and Full Address of Branch: Type of Account: Balance:
$
Name and Full Address of Branch: Type of Account: Balance:
$

** Definition of common law: You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal relationship continuously for the past one year, or
• you have declared an individual to have a status equivalent to that of your common law partner under any law of Alberta or
of Canada, or
• you and an individual are living together in a conjugal relationship where there are one or more children of the relationship
by birth or adoption

Page 3 October 2015

Page 240
Applicant Consent and Declaration
• I declare that the information on this Application for Financial Hardship ("the Application”) is true and complete and I understand
it is subject to review and assessment by the Minister of Innovation and Advanced Education (“the Minister”) in accordance with
the S tu d e n t F in a n cia l A ssista n ce A c t (Alberta).
• I understand and agree that my Alberta student aid account(s) will go back into active collection and I will be expected to start
or resume repayment of my Alberta student aid account should my financial situation improve.
• I agree to start or resume repayment of my Alberta student aid account, as required, and meet provincial default guidelines if I
return to school and apply for further financial assistance.
• I agree to provide any information or documents as requested by the Minister to verify any statements made in this Application.
• I understand that if I make a false or misleading statement or fail to disclose information as requested, I may be denied financial
assistance, and/or be required to immediately repay all financial assistance received, and/or be subject to criminal prosecution.
I understand that failure to disclose information or provide updated information as requested by the Minister may constitute the
making of a false or misleading statement.
• I understand that I must immediately notify the Minister in writing of any change in my address, marital, financial or academic
status or any change in the address or financial status of my spouse/partner.
• I acknowledge the authority of, and where a consent is required hereby irrevocably authorize the Minister of Innovation and
Advanced Education to disclose and exchange my personal information for the purpose of determining and verifying my
eligibility for the Financial Hardship program with:
- the Canada Revenue Agency, Employment and Social Development Canada and the Canada Student Loans Program
for the purpose of determining and verifying my eligibility for the Financial Hardship program and similar federal Canada
Student Loan programs;
- any other federal, provincial, territorial or municipal government departments or agencies; any educational institutions;
any consumer credit grantor, credit bureau or credit reporting agency; any employer or landlord; any person with whom I
have indicated that I have had financial dealings; any third party authorized to collect a debt owed to the Government of
Alberta; and/or the Student Aid Alberta Service Centre;
- the federal government for use in research, statistical analysis and evaluations related to student financial assistance
programs.

Signature of Applicant (in ink) Date (in ink)

Spouse/Partner Consent and Declaration (if applicable)

For the purpose of verifying the data provided in the Application for Financial Hardship ("Application"):

• I declare that I have provided my personal information included on the Application and that my personal information is true and
complete.
• I acknowledge the authority of, and where a consent is required hereby irrevocably authorize the Minister of Innovation and
Advanced Education to disclose and exchange my personal information, for the purpose of verifying the personal information I
have included in this Application and to determine and verify the Applicant’s eligibility for the Financial Hardship program with:
- any other federal, provincial, territorial or municipal government departments or agencies, any educational institutions;
any consumer credit grantor, credit bureau or credit reporting agency; any employer or landlord; any person with whom I
have indicated that I have had financial dealings; any third party authorized to collect a debt owed to the Government of
Alberta; and/or the Student Aid Alberta Service Centre.

Signature of Spouse/Partner (in ink) Date (in ink)

Page 4 October 201^a g e 241

 Program Payments & Form L - Application
Revenue Support
PO Box 28000 Stn Main for Special Consideration
Student Aid Alberta Edmonton AB T5J 4R4

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant's eligibility for the
Alberta Special Consideration program and for the administration (including for research, statistical analysis and evaluations)
and enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta),
as may be amended from time to time. The use and disclosure of the personal information is managed in accordance with
the Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or
disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4.

APPLICANT’S NAME SOCIAL INSURANCE NUMBER

ALBE RTA STUDEN1rNUMBER

GENERAL INFORMATION
Special Consideration is a program that removes your Alberta student loan and/or grant overpayment account
(“Alberta student aid account”) from active collection. Approval for the Special Consideration Program does not
relieve you from any other obligations you may have pursuant to the loan agreement for your Alberta student aid
account.
Important: I f y o u a re a p p r o v e d fo r S p e c ia l C o n s id e ra tio n :
• th e c u r r e n t c r e d it r a tin g o f y o u r A lb e r ta s tu d e n t a id a c c o u n t w ill n o t c h a n g e a s a r e s u lt o f a p p ro v a l.
I f y o u r A lb e r ta s tu d e n t a id a c c o u n t is in g o o d s ta n d in g , it w ill r e m a in in g o o d s ta n d in g . I f y o u r
A lb e r ta s tu d e n t a id a c c o u n t is in p o o r s ta n d in g (e .g . y o u h a v e d e fa u lte d o n y o u r p a y m e n ts ) , it w ill
r e m a in in p o o r s ta n d in g .
• y o u r e lig ib ility fo r fu tu re s tu d e n t a id w ill r e q u ir e y o u to r e h a b ilita te y o u r A lb e r ta s tu d e n t a id a c c o u n t
(th is m e a n s th a t y o u m u s t p a y th e o u ts ta n d in g in t e r e s t a n d m a k e th e e q u iv a le n t o f tw o m o n th s
p a y m e n ts o n y o u r lo a n s a n d / o r g r a n t o v e r p a y m e n ts ).

Special Consideration does not apply to Canada student loans. You must make separate application for
the Permanent Disability Benefit Program through the Canada Student Loans Program. To do so, contact the
National Student Loans Service Centre or your bank. Please note: Student Aid Alberta may share your
personal information with the Canada Student Loans Program if you have Canada student loans.
ELIGIBILITY FOR SPECIAL CONSIDERATION
You may be eligible for Special Consideration if:
0 You have a permanent disability.
• For the purposes of Special Consideration, a permanent disability is defined as a functional limitation
caused by a physical or mental impairment that substantially limits your ability to earn a living.
AND
0 You can demonstrate financial hardship, as follows:
• your financial situation does not allow you to make your Alberta student aid account payments, and
• your financial resources (savings, RRSPs, bonds, etc.) are not enough to substantially reduce the
balance of your Alberta student aid account.

HOW TO APPLY
1. Complete Form L (this application) and Schedule J (Income and Expense Statement).
2. Have your doctor complete all the questions on Schedule K (Medical Questionnaire), sign it and place
his/her stamp or seal on it. If your doctor has previously completed other medical documents for you to
apply for permanent disability benefits (e.g. AISH, CPP-D, etc.), you may submit these documents
instead of a Schedule K as long as the documents contain similar information to what is requested on
the Schedule K.
3. Upload or mail the entire application (Form L, Schedule J and Schedule K or other medical documents)
according to the instructions on the next page. You and your spouse/partner (if applicable) must also
include a copy of your most recent Notice of Assessment from the Canada Revenue Agency.
July 2015
Signatures required on reverse side Page 242
APPLICANT CONSENT AND DECLARATION
• I declare that the information on this application and
applicable schedules (the “Application for Special
Consideration”) is true and complete and I
understand it is subject to review and assessment by
the Minister of Innovation and Advanced Education
(“the Minister”) in accordance with the S tu d e n t
F in a n c ia l A s s is ta n c e A c t (Alberta).
• I understand and agree that my Alberta student aid
accounts will go back into active collection and I will
be expected to start or resume repayment of my
Alberta student aid account should my financial
situation improve.
• I agree to start or resume repayment of my Alberta
student aid account, as required, and meet provincial
default guidelines if I return to school and apply for
further financial assistance.
• I agree to provide any information or documents as
requested by the Minister to verify any statements
made in this Application for Special Consideration.
• I understand that if I make a false or misleading
statement or fail to disclose information as
requested, I may be denied financial assistance,
including the Alberta Special Consideration program,
and/or be required to immediately repay all financial
assistance received, and/or be subject to criminal
prosecution. I understand that failure to disclose
information or provide updated information as
requested by the Minister may constitute the making
of a false or misleading statement.
Applicant’s Signature (in ink)
SPOUSE/PARTNER CONSENT AND DECLARATION (if applicable)
For the purpose of verifying the data provided in the Application for Special Consideration:
• I hereby declare that I have given my personal
information included in the Application for Special
Consideration and my personal information is true
and complete.
• I acknowledge the authority of, and where a consent
is required hereby irrevocably authorize the Minister
of Innovation and Advanced Education to disclose
and exchange my personal information, for the
purpose of verifying the personal information I have
included in this Application for Special Consideration
and to determine and verify the Applicant’s eligibility
Spouse’s/Partner’s Signature (in ink)
UPLOAD OR MAIL YOUR FORM
Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using
e-Document Upload
Or mail to: Student Aid Alberta, Program Payments & Revenue Support, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4
• I understand that I must immediately notify the
Minister in writing of any change in my address,
marital, financial or academic status or any change
in the address or financial status of my
spouse/partner.
• I acknowledge the authority of, and where a consent
is required hereby irrevocably authorize the Minister
of Innovation and Advanced Education to disclose
and exchange my personal information for the
purpose of determining and verifying my eligibility for
the Alberta Special Consideration program with:
- the Canada Revenue Agency, Employment
and Social Development Canada and the
Canada Student Loans Program for the purpose
of determining and verifying my eligibility for the
Alberta Special Consideration program and
similar federal Canada Student Loan programs;
- any other federal, provincial, territorial or
municipal government departments or agencies;
any educational institutions; any consumer credit
grantor, credit bureau or credit reporting agency;
any employer or landlord; any person with whom
I have indicated that I have had financial
dealings; any third party authorized to collect a
debt owed to the Government of Alberta; and/or
the Student Aid Alberta Service Centre;
- the federal government for use in research,
statistical analysis and evaluations related to
student financial assistance programs.
Today’s Date (in ink)
for the Alberta Special Consideration program,
with:
- any other federal, provincial, territorial or
municipal government departments or agencies;
any educational institutions; any consumer credit
grantor, credit bureau or credit reporting agency;
any employer or landlord; any person with whom
I have indicated that I have had financial
dealings; any third party authorized to collect a
debt owed to the Government of Alberta; and/or
the Student Aid Alberta Service Centre.
Today’s Date (in ink)
 Program Payments & Form L - Application
Revenue Support
PO Box 28000 Stn Main for Special Consideration
Student Aid Alberta Edmonton AB T5J 4R4

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant's eligibility for the
Alberta Special Consideration program and for the administration (including for research, statistical analysis and evaluations)
and enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta),
as may be amended from time to time. The use and disclosure of the personal information is managed in accordance with
the Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or
disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4.

APPLICANT’S NAME SOCIAL INSURANCE NUMBER

ALBE RTA STUDEN1rNUMBER

GENERAL INFORMATION
Special Consideration is a program that removes your Alberta student loan and/or grant overpayment account
(“Alberta student aid account”) from active collection. Approval for the Special Consideration Program does not
relieve you from any other obligations you may have pursuant to the loan agreement for your Alberta student aid
account.
Important: I f y o u a re a p p r o v e d fo r S p e c ia l C o n s id e ra tio n :
• th e c u r r e n t c r e d it r a tin g o f y o u r A lb e r ta s tu d e n t a id a c c o u n t w ill n o t c h a n g e a s a r e s u lt o f a p p ro v a l.
I f y o u r A lb e r ta s tu d e n t a id a c c o u n t is in g o o d s ta n d in g , it w ill r e m a in in g o o d s ta n d in g . I f y o u r
A lb e r ta s tu d e n t a id a c c o u n t is in p o o r s ta n d in g (e .g . y o u h a v e d e fa u lte d o n y o u r p a y m e n ts ) , it w ill
r e m a in in p o o r s ta n d in g .
• y o u r e lig ib ility fo r fu tu re s tu d e n t a id w ill r e q u ir e y o u to r e h a b ilita te y o u r A lb e r ta s tu d e n t a id a c c o u n t
(th is m e a n s th a t y o u m u s t p a y th e o u ts ta n d in g in t e r e s t a n d m a k e th e e q u iv a le n t o f tw o m o n th s
p a y m e n ts o n y o u r lo a n s a n d / o r g r a n t o v e r p a y m e n ts ).

Special Consideration does not apply to Canada student loans. You must make separate application for
the Permanent Disability Benefit Program through the Canada Student Loans Program. To do so, contact the
National Student Loans Service Centre or your bank. Please note: Student Aid Alberta may share your
personal information with the Canada Student Loans Program if you have Canada student loans.
ELIGIBILITY FOR SPECIAL CONSIDERATION
You may be eligible for Special Consideration if:
0 You have a permanent disability.
• For the purposes of Special Consideration, a permanent disability is defined as a functional limitation
caused by a physical or mental impairment that substantially limits your ability to earn a living.
AND
0 You can demonstrate financial hardship, as follows:
• your financial situation does not allow you to make your Alberta student aid account payments, and
• your financial resources (savings, RRSPs, bonds, etc.) are not enough to substantially reduce the
balance of your Alberta student aid account.

HOW TO APPLY
1. Complete Form L (this application) and Schedule J (Income and Expense Statement).
2. Have your doctor complete all the questions on Schedule K (Medical Questionnaire), sign it and place
his/her stamp or seal on it. If your doctor has previously completed other medical documents for you to
apply for permanent disability benefits (e.g. AISH, CPP-D, etc.), you may submit these documents
instead of a Schedule K as long as the documents contain similar information to what is requested on
the Schedule K.
3. Mail the entire application (Form L, Schedule J and Schedule K or other medical documents) to the
address above. You and your spouse/partner (if applicable) must also include a copy of your most
recent Notice of Assessment from the Canada Revenue Agency.
June 2014
Signatures required on reverse side Page 244
APPLICANT CONSENT AND DECLARATION
• I declare that the information on this application and
applicable schedules (the “Application for Special
Consideration”) is true and complete and I
understand it is subject to review and assessment by
the Minister of Innovation and Advanced Education
(“the Minister”) in accordance with the Student
Financial Assistance A ct (Alberta).
• I understand and agree that my Alberta student aid
accounts will go back into active collection and I will
be expected to start or resume repayment of my
Alberta student aid account should my financial
situation improve.
• I agree to start or resume repayment of my Alberta
student aid account, as required, and meet provincial
default guidelines if I return to school and apply for
further financial assistance.
• I agree to provide any information or documents as
requested by the Minister to verify any statements
made in this Application for Special Consideration.
• I understand that if I make a false or misleading
statement or fail to disclose information as
requested, I may be denied financial assistance,
including the Alberta Special Consideration program,
and/or be required to immediately repay all financial
assistance received, and/or be subject to criminal
prosecution. I understand that failure to disclose
information or provide updated information as
requested by the Minister may constitute the making
of a false or misleading statement.
Applicant’s Signature (in ink)
SPOUSE/PARTNER CONSENT AND DECLARATION (if applicable)
For the purpose of verifying the data provided in the Application for Special Consideration:
• I hereby declare that I have given my personal
information included in the Application for Special
Consideration and my personal information is true
and complete.
• I acknowledge the authority of, and where a consent
is required hereby irrevocably authorize the Minister
of Innovation and Advanced Education to disclose
and exchange my personal information, for the
purpose of verifying the personal information I have
included in this Application for Special Consideration
and to determine and verify the Applicant’s eligibility
Spouse’s/Partner’s Signature (in ink)
• I understand that I must immediately notify the
Minister in writing of any change in my address,
marital, financial or academic status or any change
in the address or financial status of my
spouse/partner.
• I acknowledge the authority of, and where a consent
is required hereby irrevocably authorize the Minister
of Innovation and Advanced Education to disclose
and exchange my personal information for the
purpose of determining and verifying my eligibility for
the Alberta Special Consideration program with:
- the Canada Revenue Agency, Employment
and Social Development Canada and the
Canada Student Loans Program for the purpose
of determining and verifying my eligibility for the
Alberta Special Consideration program and
similar federal Canada Student Loan programs;
- any other federal, provincial, territorial or
municipal government departments or agencies;
any educational institutions; any consumer credit
grantor, credit bureau or credit reporting agency;
any employer or landlord; any person with whom
I have indicated that I have had financial
dealings; any third party authorized to collect a
debt owed to the Government of Alberta; and/or
the Student Aid Alberta Service Centre;
- the federal government for use in research,
statistical analysis and evaluations related to
student financial assistance programs.
Today’s Date (in ink)
for the Alberta Special Consideration program,
with:
- any other federal, provincial, territorial or
municipal government departments or agencies;
any educational institutions; any consumer credit
grantor, credit bureau or credit reporting agency;
any employer or landlord; any person with whom
I have indicated that I have had financial
dealings; any third party authorized to collect a
debt owed to the Government of Alberta; and/or
the Student Aid Alberta Service Centre.
Today’s Date (in ink)
June 2014
Page 245
 Form M
Permanent Disability-Related
Program Payments &
Revenue Support
PO Box 28000 Stn Main for the Alberta Repayment Assistance Plan for
Student Aid Alberta Edmonton AB T5J 4R4
Borrowers with Permanent Disabilities (RAP-PD)
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for the Alberta
Repayment Assistance Plan for Borrowers with Permanent Disabilities (RAP-PD) and for the administration (including for
research, statistical analysis and evaluations) and enforcement of student financial assistance programs in accordance with
the Student Financial Assistance Act (Alberta), as may be amended from time to time. The use and disclosure of personal
information is managed in accordance with the Freedom of Information and Protection of Privacy Act (Alberta). If you have
any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy
Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

APPLICANT’S NAME SOCIAL INSURANCE NUMBER

GENERAL INFORMATION
Alberta RAP-PD considers expenses that you may have that are directly related to your illness or permanent
disability. These illness or permanent disability-related expenses may have an impact on your eligibility for
RAP-PD and/or your monthly affordable payment.

The following are examples of expenses related to your illness or permanent disability that should be
reported on this form:
• Uninsured, essential medical, dental, hearing, or optical expenses, or expenses for
psychological/psychiatric care
• Uninsured expenses directly related to accommodation of your disability
• Uninsured expenses related to your care as recognized by Canada Revenue Agency
• Uninsured home renovations required to accommodate your illness or permanent disability (not
cosmetic or regular maintenance)

l— \ Important: You must submit receipts of the payment(s) you made on your disability-related
expenses within the past six months.

STATEMENT OF EXPENSES for the past six months (if applicable)

Description of Expenses Cost paid by my
(in the month of this insurance plan, if Cost not paid by my
application) applicable insurance plan TOTAL COST

TOTAL
Description of Expenses Cost paid by my
(in the first month prior to insurance plan, if Cost not paid by my
the month of this applicable insurance plan TOTAL COST
application)

TOTAL
There are more charts to be completed on the reverse side.
Please turn over.
Description of Expenses Cost paid by my
(in the second month insurance plan, if Cost not paid by my
prior to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the third month prior insurance plan, if Cost not paid by my
to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the fourth month prior insurance plan, if Cost not paid by my
to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the fifth month prior to insurance plan, if Cost not paid by my
the month of this applicable insurance plan TOTAL COST
application)

TOTAL

APPLICANT DECLARATION
I declare that all information I have provided is complete and true and I understand that it is an offence
to make a false or misleading claim and/or statement.

I have included proof of my disability-related expenses: Yes_____ No

Signature of Applicant:__________________________________ Date:

Upload or mail this form and proof of your disability-related expenses.

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit
securely using e-Document Upload

Or mail to: Student Aid Alberta, Program Payments & Revenue Support, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4
 Form M
Permanent Disability-Related
Program Payments &
Revenue Support
PO Box 28000 Stn Main for the Alberta Repayment Assistance Plan for
Student Aid Alberta Edmonton AB T5J 4R4
Borrowers with Permanent Disabilities (RAP-PD)
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for the Alberta
Repayment Assistance Plan for Borrowers with Permanent Disabilities (RAP-PD) and for the administration (including for
research, statistical analysis and evaluations) and enforcement of student financial assistance programs in accordance with
the Student Financial Assistance Act (Alberta), as may be amended from time to time. The use and disclosure of personal
information is managed in accordance with the Freedom of Information and Protection of Privacy Act (Alberta). If you have
any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy
Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

APPLICANT’S NAME SOCIAL INSURANCE NUMBER

GENERAL INFORMATION
Alberta RAP-PD considers expenses that you may have that are directly related to your illness or permanent
disability. These illness or permanent disability-related expenses may have an impact on your eligibility for
RAP-PD and/or your monthly affordable payment.

The following are examples of expenses related to your illness or permanent disability that should be
reported on this form:
• Uninsured, essential medical, dental, hearing, or optical expenses, or expenses for
psychological/psychiatric care
• Uninsured expenses directly related to accommodation of your disability
• Uninsured expenses related to your care as recognized by Canada Revenue Agency
• Uninsured home renovations required to accommodate your illness or permanent disability (not
cosmetic or regular maintenance)

l— \ Important: You must submit receipts of the payment(s) you made on your disability-related
expenses within the past six months.

STATEMENT OF EXPENSES for the past six months (if applicable)

Description of Expenses Cost paid by my
(in the month of this insurance plan, if Cost not paid by my
application) applicable insurance plan TOTAL COST

TOTAL
Description of Expenses Cost paid by my
(in the first month prior to insurance plan, if Cost not paid by my
the month of this applicable insurance plan TOTAL COST
application)

TOTAL
There are more charts to be completed on the reverse side.
Please turn over.
June 2014
Page 248
Description of Expenses Cost paid by my
(in the second month insurance plan, if Cost not paid by my
prior to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the third month prior insurance plan, if Cost not paid by my
to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the fourth month prior insurance plan, if Cost not paid by my
to the month of this applicable insurance plan TOTAL COST
application)

TOTAL

Description of Expenses Cost paid by my

(in the fifth month prior to insurance plan, if Cost not paid by my
the month of this applicable insurance plan TOTAL COST
application)

TOTAL

APPLICANT DECLARATION
I declare that all information I have provided is complete and true and I understand that it is an offence
to make a false or misleading claim and/or statement.

I have included proof of my disability-related expenses: Yes_____ No

Signature of Applicant:__________________________________ Date:

Mail this form and proof of your disability-related expenses to:

Student Aid Alberta

Program Payments & Revenue Support
PO Box 28000 Stn Main
Edmonton AB T5J 4R4

June 2014
Page 249
Canada Application for Financial Assistance
S tu d en t Aid A lberta
^A^OwbCyJl
Student Aid Alberta
Full-Time Post-Secondary Studies 2015/2016
P le a s e r e a d th e Quick Tips Booklet b e fo re c o m p le tin g th is a p p lic a tio n .
15/16 F
Not sure you are eligible to apply? See Quick Tips, page 4.
Student Aid Alberta must receive this application at least 30 days before this year’s program ends in order to process.

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4

Personal Information

Last Name (current full legal name) Social Insurance Number

I I I I I I I I I I I I I
M id d le
First Name (current full legal name) Initial Gender |__| Male _J Female

If you have changed your name since you last applied, see Quick Tips, p.12 #1.
□ Birthdate Day Month Year
__ i__ _l___ l_ __ I__
Apartment or Box Number
Marital Status: (check one)
• for definition of dependent children, see page 3
Street Address • for definition of common law, see Schedule 2
□ Single (no dependent children)

City/Town Q Single (with dependent children)

I I Separated/Divorced/Widowed (no dependent children)
I I I I I I I I l I I I I I I I I I \ Separated/Divorced/Widowed (with dependent children)
Prov/State Country Postal/Zip Code
I \ Married (complete Schedule 2)
I I I I I I I I I I I □ Common Law (complete Schedule 2)
Mobile Number (format: 999-999-9999) to receive text messages
Maiden Name (if applicable)

Telephone Number (format: 999-999-9999)

Date completed/last attended regular High School
JL (excludes upgrading)
Email Address Month Year

_ l_____ L. ___I__

Citizenship Status: (check one)

If you are a single student with no dependent children, have
(Students with a study permit are not eligible for funding from
you been available for full-time work for 2 or more years since
Student Aid Alberta)
you left high school?
J Canadian Q Permanent Resident
_| Protected Person (see Quick Tips, p.12 #2)
LI Yes U No

Alberta Student Number (mandatory)

Have you lived in Alberta all your life? (see Quick Tips, p.12 #3) (obtained from Alberta Transcript of High School Achievement)
I Yes J No If no, is Alberta the last province you have (see Quick Tips, p.13 #5)
lived in for 12 consecutive months without
being a full-time post-secondary student?
[ 1 Yes |_J No Have you received Canada Student Loan Funding from a
province other than Alberta?
Do you have a permanent disability?
I Yes _| No
□ Yes _ | No (If yes, see Quick Tips, pp.10-11
and complete a Schedule 4) Total Income from Line 150 of your 2014 Income Tax Return
If you wish to declare your Aboriginal heritage, please check the (mandatory) (see Quick Tips, p.13 #6)
box that applies to you. Quick Tips, p.13 #4 explains why we ask
you for this information. $

I ] Status Indian/First Nations J Metis

I I Non-Status Indian/First Nations I_J Inuit

01/16 APP-TYPE 1 APP-YEAR 2015/2016 APP-FORM-P Page 250

For Office Use Only App ID
5
 Page 2
F m o rn o n rM / P n n t a r t In fn r m a tin n Student Aid Alberta will contact the person below to obtain your new address, phone number
Emergency oom aci iniormanon or e m a j| address if unable to contact you using the information you provided on page 1.
Last Name City/Town

I I I I I I I I I I I I I I I I
Jliddle
First Name nitial Postal/Zip Code

I I I I I I I I I I I I I □ _L I I I I I I
Apartment or Box Number Telephone (format: 999-999-9999)

JL
Street Address Relationship to You

I I I I I I I I I I I I I I I I
Information for the Four Months Before Starting this School Term

How many months will you be a full-time student before I_| 0 Months 1 Month _) 2 Months _ ] 3 M onths_) 4 Months
starting this school term? (see Quick Tips, p.13 #7)
Your total gross income for the 4 months before starting this school term will be $
(This does not include student aid loan or grant funding)
Will you be living with your parent(s) before starting this school term? J Yes [_ ) No

Full-time Studies Information (classes start between August 1, 2015 and July 31, 2016)

Educational Institution
If you are a concurrently enrolled student, enter
your primary institution and complete Schedule 3,
City/Town Prov/State Part 1 (see Quick Tips, p.13 #8).
Concurrently enrolled means you are
simultaneously attending more than one school
Country
on a part-time basis (less than 60% of a full-time
course load at each educational institution).

Program (see Quick Tips, p.14 #9)

Program Outcome
J Certificate J Diploma J Degree
Program Specialization/Major (see Quick Tips, p.14 #9)
J Degree - Masters Degree - Doctoral
□ Journeyman Certificate

Are you enrolled in a correspondence/e-learning/distance study program? □ Yes [ J No

What year of this program will you be in? (check one) _J 1st year or less __]
_J 2nd year J 3rd
: year _ ) 4th or 5th year
(see Quick Tips, p.14 #10)
Length of your program of studies (check one) □ 1 year or less [_) 2 years ^_| 3 years U 4 or 5 years

Enter your program session start and end dates for the 2015/2016 school year. These dates cannot exceed 12 months.
Check with your school as incorrect dates will delay processing.
Start End
Day Month Year Day Month Year

__ I__ J _____L __ I__ _I_ J _____L __ I__

Will you complete your program of study and receive your post-secondary certificate, I_| Yes _| No
diploma, or degree by the session end date? (see Quick Tips, p.14 #11)

School Student Identification Number for the school you are planning to attend (if known)
I I I I I I I I I I I
If you are attending a private vocational school, enter the campus address here —
If you are going on an exchange/field study program, complete Schedule 3, Part 2.

Page 251
 Page 3
Dependent Children Information (se e Q u ic k T ip s, p . 14 # 1 2 )

Dependent children means those children w h o a r e liv in g w i t h y o u a n d for whom you and/or your spouse/partner are legally responsible. If you have
more than four dependants, attach the information separately. The allowable child care cost is up to $724 per month per child without receipts. You may
be considered for more if receipts are provided (see Quick Tips, p.7).
M o n th ly C h ild C a r e C o s ts (a fte r s u b s id y )
B ir th d a te (d a y /m o n th /y e a r ) R e la tio n s h ip to You
(for children under 12 years of age)

I I I

}
J ____ L J ____ I____ l_

J___ I___ L
I I
Educational Costs and Available Resources
Monthly living costs are automatically calculated (se e Q u ic k T ip s , p . 7)

While attending school I will live: _ | with parents _ | other

Monthly
Monthly child support payments you make (see Quick Tips, p.14 # 1 3 )--------- ►

Monthly Resources While in School Monthly

Wages/Salary (net income) (see Quick Tips, p.15 #14)
Spousal/Partner Net Income (see Quick Tips, p.15 #15)
Assistantships after deductions
Stipends
RESPs and Voluntary Contributions from Parents (see Quick Tips, p.15 #16)
Alimony and/or Child Support you receive
Employment Insurance (El Benefits) (see Quick Tips, p.15 #17)
— Important:
Remember to
Assured Income for the Severely Handicapped (AISH) (see Quick Tips, p.15 #18)
enter monthly
Workers’ Compensation Benefits resources in
Aboriginal Affairs and Northern Development Canada/Band Funds this section.
Other Income (e.g. pensions, rental property, business). Do not include Child Tax Benefits,
GST Credit, Income Tax Refund, or Registered Disability Savings Plan.
List:

Education Costs for 2015/2016 Study Period (see Quick Tips, p.15 #19)
Tuition
Mandatory Fees (does not include housing/residence costs)
Books/Supplies/lnstruments
Computer Costs (see Quick Tips, p. 16 #20)

Other Resources Available to Me

Savings you will have when you start school (include TFSAs) (see Quick Tips, p.16 #21) Keep all documents
related to costs and
Assets (e.g. term deposits, bonds, stocks, GICs, etc.) (see Quick Tips, p.16 #22)
resources as they
List: must be verified
Registered Retirement Savings Plans (RRSPs) (see Quick Tips, p.16 #23) when audited.
Other Resources List: (see Quick Tips, p.16 #26)

Scholarships/Bursaries/Fellowships (see Quick Tips, p.16 #24)

(e.g. Rutherford, Athletic, Louise McKinney, other) Enter total amount ^

Requesting an Amount (optional)

If you do not enter an amount, a calculation will be done for you based
on the information you have provided. If you want to request a certain
amount of funding, enter the amount here, (see Quick Tips, p.16 #25) —

Page 252
 Page 4

Innovation and Advanced Education is collecting the personal information under the authority of sections 33(a) and (c) of the Freedom
of Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for financial assistance, to administer
(including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the
Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as
may be amended from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom
of Information and Protection of Privacy Act (Alberta).
The personal information in this Application may be disclosed to:
(a) federal government departments or agencies (including Employment and Social Development Canada) to verify any information
you have provided, to determine your eligibility for financial assistance, to administer student financial assistance programs,
and to conduct research, statistical analysis, and evaluations related to student financial assistance programs;
(b) educational institutions to verify any information you have provided, to determine your eligibility for financial assistance, to assist
your educational institution to respond to your inquiries concerning the status of your Application and to administer student
financial assistance programs;
(c) any credit bureau to verify any information you have provided, to determine your eligibility for financial assistance and to
administer student financial assistance programs.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre
toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Applicant Declaration - Important - Read Carefully

The undersigned applicant (“I” or the “Applicant”) acknowledges and agrees that this application for financial assistance (the
“Application”), together with any and all funds or other financial assistance received by the Applicant pursuant the Students Finance
Act (Alberta), the Student Loan Act (Alberta) or the Student Financial Assistance Act (Alberta) from Her Majesty the Queen in right of
Alberta as represented by the Minister of Innovation and Advanced Education (the “Minister” or “Innovation and Advanced Education")
pursuant to this or any other application, shall be subject to, governed by and form part of the Master Student Financial Assistance
Agreement, as amended from time to time, entered into between the Applicant and the Minister. Information on obtaining a copy of
the Master Student Financial Assistance Agreement can be obtained at studentaid.alberta.ca.

I declare and warrant that:
• the information that I have provided in this Application, and
in all applicable Schedules, is true and complete, including
without limitation the information that I have provided regarding
my savings and assets, including stocks, bonds, savings
certificates, term deposits and RRSPs, and I understand that
the information that I have provided is subject to review and
assessment by the Minister in accordance with the Student
Financial Assistance Act (Alberta).
• I have not applied to or received student financial assistance
from another province or territory for the same period for which
I am applying for financial assistance in this Application.
I agree to:
• immediately notify Innovation and Advanced Education in
writing of any change in my name, address, marital or common
law partner status, financial circumstances, academic status
or study period, any change in the address or financial
circumstances of my spouse/partner, any change in the
financial circumstances of my parents or guardians, or to
any other information contained in this Application.
• provide information or documents as requested by Innovation
and Advanced Education to verify any statements made in
this Application.
* use any financial assistance provided to pay my academic
fees first; then I will pay other educational and living costs
associated with my program of studies.
» all or a portion of any financial assistance provided to me
being directly remitted to my educational institution where my
educational institution requests the payment of my tuition and
mandatory fees.
understand that:
» I may be denied financial assistance if I fail to notify Innovation
and Advanced Education in writing of any change in my
financial circumstances, marital or common law partner status,
academic status or study period, or fail to provide documents
or information as requested by Innovation and Advanced
Education to verify statements made in this Application.
» if I make a false or misleading statement in this Application
I may be denied financial assistance, and/or required to
immediately repay all financial assistance received, and/or
subject to criminal prosecution.
» failure to disclose information or provide updated information
as requested by Innovation and Advanced Education may
constitute the making of a false or misleading statement.

I have read, understood, and agree to be bound by all of the declarations contained within page 4 of this Application.

Applicant Signature Today’s Date

Day Month Year

I I I I J___ I___ L
Page 253
Parental* Personal and Financial Information 2015/2016 Schedule 1
*This includes parents and step parents.
Complete Schedule 1 if:
15/16 S1
• you are single and have been out of high school for less than 4 years, and • you have not been available for full-time work for 2 or more
years since you left high school
Applicant’s Last Name Initials Social Insurance Number

Part A (Mandatory) - To Determine Provincial Residency

Are BOTH of your parents deceased or do you have a court appointed legal
| Yes _ | No
guardian? (If yes, do not complete the remainder of Schedule 1)
Does at least one of your parents reside in Alberta? 1 Yes I No
• If your parents do not live in Alberta, where do they currently reside?
Prov/State Country

_L
Month Year
If your parents do not live in Alberta, indicate the date they moved out of Alberta
_l_____l_ __ I__
If your parents have moved out of Alberta, did you stay
| Yes L I No
in Alberta to begin or continue post-secondary studies?
I wish to be considered for federal grants and loans, i Yes I No
and the Alberta Low Income Grant. (See Quick Tips, p.6) ,_____________
If yes, continue to Part B
Part B (Optional) - To Determine Your Eligibility for Federal Grants and Loans, and Alberta Low Income Grant

You must complete Part B if you wish to be considered
for federal loans and the following grants:
• Federal grant for Students from Low-Income Families
($250 per month of studies)
• Federal grant for Students from Middle-Income Families
($100 per month of studies)
Federal grant for Students with a Permanent Disability
($2,000 per academic year)
Federal grant for Services and Equipment for Students with
a Permanent Disability (up to $8,000 per academic year)
Alberta Low Income Grant ($250 per month of studies)

Notice: If your parent(s) do not wish to share their personal information with you to complete Part B, they may contact the Student
Aid Alberta Service Centre toll free at 1-855-606-2096 for further instructions.

Parent 1 Last Name Parent 1 First Name

Parent 2 Last Name Parent 2 First Name

Is there a public transit system available from your parents’ home to the school you will be attending? Yes J No
(This does not include Greyhound, Red Arrow, etc.)
Family Size • include all children 0-17 years • include parent 1 & 2 as listed above
• include children 18-22 (if they are full-time students) • do not include children over age of 22

Number of people in your family

Number of children attending post-secondary institutions in 2015/2016

Parental Total Income (see Quick Tips, p.13 #6)

Parent 1 Total income (Line 150 of 2014 Income Tax Return)

Parent 2 Total income (Line 150 of 2014 Income Tax Return)

Reduced Parental Total Income Fill in this section if either parent’s annual income from all sources (work, government or other)
is expected to be lower than Parental Total Income from line 150 above.

Parent 1 estimated yearly income

Parent 2 estimated yearly income

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4
Page 254
Spouse/Partner Information 2015/2016 Schedule 2
Applicants who are Married or Common Law* 1 5 /1 6 S2
* You are considered to have a common law partner if: you have declared an individual to have a status equivalent to that of
your common law partner under any law of Alberta or of Canada, or
• you and an individual have lived together in a conjugal relationship
continuously for the past one year, or you and an individual are living together in a conjugal relationship where
there are one or more children of the relationship by birth or adoption.

Applicant’s Last Name Initials Social Insurance Number

I I I I I I I I I I I I I I I

Spouse/Partner Information and Declaration: (to be completed by Applicant’s spouse/partner)

Notice to Spouse/Partner: If you do not wish to include your personal information with the Applicant’s Application package,
you may submit a completed Schedule 2 separate from the Application to: Student Aid Alberta, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.

Spouse/Partner Information
Spouse/Partner Social Insurance Number

Spouse/Partner Last Name Spouse/Partner First Name

Spouse/Partner Birthdate Date spouse/partner completed/last attended regular High School

(excludes upgrading)
Day Month Year
Month Year
__ i__ I , , 1 ___i__
J _____ L __ l__

Have you lived in Alberta all your life? □ Yes LI No

If no, is Alberta the last province you have lived in for 12 consecutive months without being a full-time student? _| Yes No

Total income (Line 150 of 2014 Income Tax Return) (mandatory) (see Quick Tips p.13 #6) $

Spouse/Partner Income Status

I Employed
_| Unemployed with income (WCB, El, etc.)
J Assured Income for the Severely Handicapped (AISH)
J Aboriginal Affairs and Northern Development Canada/Band Funds
I Unemployed due to medical condition (Keep your doctor’s letter as this will be audited)
_| Unemployed no income

Spouse/Partner Gross Monthly Income $

Spouse/Partner Net Monthly Income (this amount must equal

the Spousal/Partner Net Income entered on Page 3) } (see Quick Tips
p.15 #15)

Month Year
Date income starts
I ___ I____ l ____ l____

If your income will end during the Applicant’s study period, Month Year
indicate date
■ ■ l ___ 1_____ 1_____ 1____
Spouse/Partner School Status
Will you be a full-time student at any time during the Applicant’s study period? □ Yes □ No

If yes, date you Day Month Year Date you Day Month Year
start school ■ 1__ i i__ L__ 1____1____1___ end school ■ 1 ■ l 1__ 1___ 1____1___
If both you and the Applicant are attending full-time studies, you should both complete a separate application form for student aid.

Signatures required on next page Page 255

Spouse/Partner Information 2015/2016 Schedule 2
Applicants who are Married or Common Law

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify the Applicant’s eligibility for financial assistance,
to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial
Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with FOIP.
The personal information may be disclosed to:
• federal, provincial or territorial government departments or agencies to verify any information the Applicant provided, determine
the eligibility of the Applicant for financial assistance and to administer student financial assistance programs.
• the federal government for use in research, statistical analysis and evaluations related to student financial assistance programs.
• Alberta Fluman Services to operate and administer provincial and federal student financial assistance programs, including your
eligibility, and the eligibility of the Applicant, for financial assistance.
• any municipal government department or agency, landlord, lending institution, credit bureau or employer to verify any information
the Applicant provided, to determine the eligibility of the Applicant for financial assistance and to administer student financial
assistance programs.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box
28000 Stn Main, Edmonton AB T5J 4R4.

Spousal/Partner Declaration:
• I declare that the information given on this Schedule is true and complete.

For the purpose of verifying the data provided in this Application for student financial assistance, I hereby consent to the release,
by Canada Revenue Agency to an official of Innovation and Advanced Education, of information from my income tax returns and, if
applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant
to and used solely for the purpose of determining and verifying the Applicant’s eligibility, entitlement for and the general administration
and enforcement of the student financial assistance programs under the Canada Student Loans Act, the Canada Student Financial
Assistance Act, the Students Finance Act (Alberta), the Student Loan Act (Alberta) and the Student Financial Assistance Act (Alberta).
This authorization is valid for the taxation year prior to the year of signature of this consent, the year of signature of this consent and
any other subsequent taxation year for which assistance is requested by the Applicant.

Signature of Spouse/Partner Today’s Date

Day Month Year
X
_ i _ l i l l I I !

Upload or Mail Your Form

Send documents electronically* Mailing Address

1. Visit studentaid.alberta.ca STUDENT AID ALBERTA
2. Sign in via SFS Login PO BOX 28000 STN MAIN
3. Submit securely using e-Document Upload EDMONTON AB T5J 4R4
‘For assistance: e-Doc Upload FAQ

Page 256
Concurrent Enrollment 2015/2016 Schedule 3
Exchange/Field Study Programs 15/16 S3
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom o f
Inform ation and Protection o f Privacy A c t (Alberta) (“FOIP”) to determine and verify your eligibility for financial assistance, to administer (including
research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the Student Financial
Assistance A c t (Alberta), the Canada S tudent Loans A c t and the Canada S tudent Financial Assistance A c t , each as may be amended from
time to time. The use and disclosure of your personal information is managed in accordance with FOIP. If you have any questions about the
collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Applicant s Last Name Initials Social Insurance Number

Part 1: Concurrent Enrollment (see Q uick Tips, p .1 3 #8)

Concurrent enrollment means you are simultaneously attending more than one school on a part-time basis
(less than 60% of a full-time course load at each education institution).
• If you are concurrently enrolled, enter your primary educational institution on Page 2 of this application
(Full-time Studies Information section)
• You must choose one of the institutions as your “ primary institution” . Your primary institution will be responsible for confirming
your registration.
• Your course(s) at each school will be reviewed to determine whether you can be considered a full-time student for student
aid purposes.

Enter your primary institution:

Enter your additional institution(s):

I I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I I I I I I I I I I
To verify full-time status, you must attach documents from your primary and additional institutions stating:
• Course Name(s)
• Course Weight(s)/Credit(s)
• Session Start and End Dates
• Course Costs

Part 2: Exchange/Field Study Students Only

Enter your home educational institution:

I I I I I I I I I I I I I I I I I I I I I I I I I

Note: Your home institution is where tuition costs are paid and is also listed in the Full-time Studies Information section on Page 2
of this application.
Attach a letter of confirmation from your home institution or an acceptance letter from the host institution. Your letter should confirm
the actual start and end dates of your Exchange or Field Study Program and list your costs for Tuition, Mandatory Fees, and Books.

What is your airfare cost (if applicable)?

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4
Page 257
 Student Aid Alberta
Canada Application for Financial Assistance Student Aid Alberta
Full-Time Post-Secondary Studies 2014/2015
Please read the Quick Tips Booklet before co m pleting this application.
14/15 F
• Not sure you are eligible to apply? See Quick Tips, page 4.
• Student Aid Alberta must receive this application at least 30 days before this year’s program ends in order to process.
• If you are a student with a permanent disability and need to submit a Schedule 4, print a Schedule 4 from studentaid.alberta.ca.

Mail to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton, AB T5J 4R4

PERSONAL INFORMATION

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) Initial Gender □ Male □ Female

If you have changed your name since you last applied, see Quick Tips,
□
p .1 2 # 1 .
Birthdate Day Month Year
__ i__ _l___ l_ __ I__
Apartment or Box Number
Marital Status: (check one)
(For definition o f dependent children, see page 3.
Street Address F or definition o f com m on law, see Schedule 2)
I I Single (no dependent children)
□ Single (with dependent children)
City/Town
Q Separated/Divorced/Widowed (no dependent children)
I I Separated/Divorced/Widowed (with dependent children)
Prov/State Country Postal/Zip Code I I Married (com plete Schedule 2)
I I l l I I I I I I I □ Common Law (com plete Schedule 2)
Telephone (format: 999-999-9999)
Maiden Name (if applicable)

Alternate Telephone (format: 999-999-9999)

Date completed/last attended regular High School
(excludes upgrading)
Email Address Month Year

_ l_____ L. ___I__

Citizenship Status: (check one)

If you are a single student with no dependent children, have
(Students w ith a study pe rm it are n o t eligible fo r financial
you been available for full-time work for 2 or more years since
assistance from S tudent A id Alberta)
you left high school?
□ Canadian □ Permanent Resident (Landed Immigrant)
I i Yes Q No
□ Convention Refugee (see Quick Tips, p.12 #2)
Alberta Student Number (mandatory)
Have you lived in Alberta all your life? (see Quick Tips, p.12 #3) (obtained from Alberta High School Transcript)
I I Yes Q No If no, is Alberta the last province you have (see Quick Tips, p.13 #5)
lived in for 12 consecutive months without
being a full-time post-secondary student?
□ Yes □ No Have you received Canada Student Loan Funding from a
province other than Alberta?
Do you have a permanent disability?
□ Yes □ No
□ Yes □ No (If yes, see Quick Tips, pp.10-11
and complete a Schedule 4) Total Income from Line 150 of your 2013 Income Tax Return
If you wish to declare your Aboriginal heritage, please check the (mandatory) (see Quick Tips, p.13 #6)
box that applies to you. Quick Tips, p.13 #4 explains why we ask
you for this information. $

□ Status Indian/First Nations □ Metis

□ Non-Status Indian/First Nations □ Inuit

0 1 / 1 5 A P P - T Y P E 1 A P P - Y E A R 2 0 1 4 /2 0 1 5 A P P - F O R M - P F o r O ffic e U s e O n ly A p p ID Pa ie 258
 Page 2
Stud en t Aid A lberta will contact the person below to obtain your new address, phone num ber
EMERGENCY CONTACT INFORMATION or email address if unable to contact you using the information you provided on page 1.

Last Name City/Town

I I I I I I I I I I I I I I I
M id d le
First Name Initial Postal/Zip Code

I I I I I I I I I I I I I □ 1 I I I I I I
Apartment or Box Number Telephone (format: 999-999-9999)

I I I I I I I I I I I I I I I
Street Address Relationship to You

I I I I ............................................... I I

INFORMATION FOR THE FOUR MONTHS BEFORE STARTING THIS SCHOOL TERM

How many months will you be a full-time student before □ 0 Months □ 1 Month □ 2 Months □ 3 Months □ 4 Months
starting this school term? (see Quick Tips, p.13 #7)
Your total gross income for the 4 months before starting this school term will be $
(This does not include student aid loan or grant funding)
Will you be living with your parent(s) before starting this school term? □ Yes □ No

FULL-TIME STUDIES INFORMATION (CLASSES START BETWEEN AUGUST 1, 2014 AND JULY 31, 2015)

Educational Institution
If you are a concurrently enrolled student, enter
your primary institution and complete Schedule 3,
City/Town Prov/State Part 1 (see Quick Tips, p.13 #8)

I I I I I I I I I I I I I I I Concurrently enrolled means you are

simultaneously attending more than one school
Country
on a part-time basis (less than 60% of a full-time
course load at each educational institution).
I I I I I I I I I I I I I
Program (see Quick Tips, p.14 #9)
Program Outcome
□ C ertifica te D ip lo m a D eg ree
Program Specialization/Major (see Quick Tips, p.14 #9)
□ D eg re e - M asters

□ D eg re e - D octoral

Are you enrolled in a correspondence/e-learning/distance study program? □ Yes □ No

What year of this program will you be in? (check one) □ 1st year or less □ 2nd year Q 3rd year Q 4th or 5th year
(see Quick Tips, p.14 #10)

Length of your program of studies (check one) □ 1 year or less □ 2 years □ 3 years □ 4 or 5 years

Enter your program session start and end dates for the 2014/2015 school year. These dates cannot exceed 12 months.
Check with your school as incorrect dates will delay processing.

Start End
D ay M on th Year D ay M on th Y ear

_I_ J _____ L l l J _____ L l

Will you complete your program of study and receive your post-secondary certificate, □ Yes □ No
diploma, or degree by the session end date? (see Quick Tips, p.14 #11)

School Student Identification Number for the school you are planning to attend (if known)
I I I I I I I I I I I

If you are attending a private vocational school, enter the campus address here —
If you are going on an exchange/field study program, complete Schedule 3, Part 2.

Page 259
 Page 3
DEPENDENT CHILDREN INFORMATION

Dependent children means those children w h o a r e liv in g w i t h y o u a n d for whom you and/or your spouse/partner are legally responsible. If you have
more than three dependants, provide all the following information on a separate piece of paper and attach to this application, (see Quick Tips, p.14 #12)
M o n th ly C h ild C a r e C o s ts (a fte r s u b s id y )
Last N am e F irs t N a m e B ir th d a te (d a y /m o n th /y e a r ) R e la tio n s h ip to You
(fo r c h ild re n u n d e r 12 y e a rs o f a g e )

J\
i I i i I i i i "I
I
$
i 1 i i 1 i i i I
I
1 1
_____1_____ _____ 1_____ 1_____ _____ 1_____ 1_____ 1____

EDUCATIONAL COSTS AND AVAILABLE RESOURCES

Monthly living costs are automatically calculated (see Quick Tips, p. 7)

While attending school I will live: □ with parents □ other Monthly

Monthly child support payments you make (see Quick Tips, p.14 #13)

Monthly Resources While in School Monthly

Wages/Salary (net income) (see Quick Tips, p.15 #14)
Spousal/Partner Net Income (see Quick Tips, p.15 #15)
Assistantships after deductions
Stipends
RESPs and Voluntary Contributions from Parents (see Quick Tips, p.15 #16)
Alimony and/or Child Support you receive
Employment Insurance (El Benefits) (see Quick Tips, p.15 #17)
— Important:
Remember to
Assured Income for the Severely Handicapped (AISH) (see Quick Tips, p.15 #18)
enter monthly
Workers' Compensation Benefits resources in
Aboriginal Affairs and Northern Development Canada/Band Funds this section.
Other Income (e.g. pensions, rental property, business). Do not include Child Tax Benefits,
GST Credit, Income Tax Refund, or Registered Disability Savings Plan.
List:

Education Costs for 2014/2015 Study Period (see Quick Tips, p.15 #19)
Tuition
Mandatory Fees (does not include housing/residence costs)
Books/Supplies/lnstruments
Computer Costs (see Quick Tips, p.16 #20)

Other Resources Available to Me

Savings you will have when you start school (see Quick Tips, p.16 #21) Keep all documents
Assets (e.g. Tax-Free Savings Account, term deposits, bonds, stocks, GICs, etc.)
related to costs and
List: (see Quick Tips, p.16 #22) resources as they
must be verified
Registered Retirement Savings Plans (RRSPs) (see Quick Tips, p.16 #23)
when audited.
Other Resources List: (see Quick Tips, p.16 #26)

Scholarships/Bursaries/Fellowships (see Quick Tips, p.i6#24)

(e.g. Rutherford, Athletic, Louise McKinney, other) Enter total amount------►

Requesting an Amount (optional)

If you do not enter an amount, a calculation will be done for you based
on the information you have provided. If you want to request a certain
amount of funding, enter the amount here, (see Quick Tips, p.16 #25) -

Page 260
 Page 4

Innovation and Advanced Education is collecting the personal information under the authority of sections 33(a) and (c) of the Freedom
of Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for financial assistance, to administer
(including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the
Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as
may be amended from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom
of Information and Protection of Privacy Act (Alberta).
The personal information in this Application may be disclosed to:
(a) federal government departments or agencies (including Employment and Social Development Canada) to verify any information
you have provided, to determine your eligibility for financial assistance and to administer student financial assistance programs,
and to conduct research, statistical analysis, and evaluations related to student financial assistance programs;
(b) educational institutions to verify any information you have provided, to determine your eligibility for financial assistance, to assist
your educational institution to respond to your inquiries concerning the status of your Application and to administer student
financial assistance programs;
(c) any credit bureau to verify any information you have provided, to determine your eligibility for financial assistance and to
administer student financial assistance programs.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre
toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

APPLICANT DECLARATION - Important - Read Carefully

The undersigned applicant (“I” or the “Applicant”) acknowledges and agrees that this application for financial assistance (the
“Application”), together with any and all funds or other financial assistance received by the Applicant pursuant the Students Finance
Act (Alberta), the Student Loan Act (Alberta) or the Student Financial Assistance Act (Alberta) from Her Majesty the Queen in right of
Alberta as represented by the Minister of Innovation and Advanced Education (the “Minister” or “ Innovation and Advanced Education”)
pursuant to this or any other application, shall be subject to, governed by and form part of the Master Student Financial Assistance
Agreement, as amended from time to time, entered into between the Applicant and the Minister. Information on obtaining a copy of
the Master Student Financial Assistance Agreement can be obtained at studentaid.alberta.ca.

I declare and warrant that:
• the information that I have provided in this Application, and
in all applicable Schedules, is true and complete, including
without limitation the information that I have provided regarding
my savings and assets, including stocks, bonds, savings
certificates, term deposits and RRSPs, and I understand that
the information that I have provided is subject to review and
assessment by the Minister in accordance with the Student
Financial Assistance Act (Alberta).
• I have not applied to or received student financial assistance
from another province or territory for the same period for which
I am applying for financial assistance in this Application.
I agree to:
• immediately notify Innovation and Advanced Education in
writing of any change in my name, address, marital or common
law partner status, financial circumstances, academic status
or study period, any change in the address or financial
circumstances of my spouse/partner, any change in the
financial circumstances of my parents or guardians, or to
any other information contained in this Application.
• provide information or documents as requested by Innovation
and Advanced Education to verify any statements made in
this Application.
* use any financial assistance provided to pay my academic
fees first; then I will pay other educational and living costs
associated with my program of studies.
» all or a portion of any financial assistance provided to me
being directly remitted to my educational institution where my
educational institution requests the payment of my tuition and
mandatory fees.
understand that:
» I may be denied financial assistance if I fail to notify Innovation
and Advanced Education in writing of any change in my
financial circumstances, marital or common law partner status,
academic status or study period, or fail to provide documents
or information as requested by Innovation and Advanced
Education to verify statements made in this Application.
» if I make a false or misleading statement in this Application
I may be denied financial assistance, and/or required to
immediately repay all financial assistance received, and/or
subject to criminal prosecution.
» failure to disclose information or provide updated information
as requested by Innovation and Advanced Education may
constitute the making of a false or misleading statement.

I have read, understood, and agree to be bound by all of the declarations contained within page 4 of this Application.

Applicant Signature Today’s Date

Day Month Year

I I I I J___ I___ L
Page 261
Parental* Personal and Financial Information 2014/2015 Schedule 1
*This includes parents and step parents.
Complete Schedule 1 if:
14/15 S1
• you are single and have been out of high school for less than 4 years, and Mail to:
• you have not been available for full-time work for 2 or more years since Student Aid Alberta, PO Box 28000 Stn Main,
you left high school Edmonton, AB T5J 4R4

Applicant’s Last Name Initials Social Insurance Number

I I I I I I I I J__ I__ I__ I__ L

PART A (MANDATORY) - TO DETERMINE PROVINCIAL RESIDENCY

Are BOTH of your parents deceased or do you have a court appointed legal
I i Yes Q No
guardian? (If yes, do not complete the remainder of Schedule 1)
Does at least one of your parents reside in Alberta? □ Yes □ No
• If your parents do not live in Alberta, where do they currently reside?
Prov/State Country

_L I I I I I I I I I I I I I I I I
Month Year
• If your parents do not live in Alberta, indicate the date they moved out of Alberta
_)______L_ __ l__
• If your parents have moved out of Alberta, did you stay in Alberta
□ Yes Q No
to begin or continue post-secondary studies?
I wish to be considered for federal grants and loans, and the
□ Yes Q No
Alberta Low Income Grant. (See Quick Tips, p.6)
->■ If yes, continue to Part B

PART B (OPTIONAL) - TO DETERMINE YOUR ELIGIBILITY FOR FEDERAL GRANTS AND LOANS,
AND ALBERTA LOW INCOME GRANT

You must complete Part B if you wish to be considered Federal grant for Students with a Permanent Disability
for federal loans and the following grants: ($2,000 per academic year)
• Federal grant for Students from Low-Income Families Federal grant for Services and Equipment for Students with
($250 per month of studies) a Permanent Disability (up to $8,000 per academic year)
• Federal grant for Students from Middle-Income Families Alberta Low Income Grant ($120 per month of studies)
($100 per month of studies)

Notice: If your parent(s) do not wish to share their personal information with you to complete Part B, they may contact the Student
Aid Alberta Service Centre toll free at 1-855-606-2096 for further instructions.

Parent 1 Last Name Parent 1 First Name

I I I I I I I I I I I I I I ! I I I ! I I I I I I ! I I I I I I I I
Parent 2 Last Name Parent 2 First Name

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I !
Is there a public transit system available from your parents’ home to the school you will be attending? □ Yes □ No
(This does not include Greyhound, Red Arrow, etc.)
Family Size • include all children 0-17 years • include parent 1 & 2 as listed above
• include children 18-22 (if they are full-time students) • do not include children over age of 22

Number of people in your family

Number of children attending post-secondary institutions in 2014/2015

Parental Total Income (see Quick Tips, p.13 #6)

Parent 1 Total income (Line 150 of 2013 Income Tax Return)

Parent 2 Total income (Line 150 of 2013 Income Tax Return)

Reduced Parental Total Income Fill in this section if either parent’s annual income from all sources (work, government or other)
is expected to be lower than Parental Total Income from line 150 above.

Parent 1 estimated yearly income

Parent 2 estimated yearly income

Page 262
Spouse/Partner Information 2014/2015 Schedule 2
Applicants who are Married or Common Law* 1 4 /1 5 S2
• You are considered to have a common law partner if: you and an individual are living together in a conjugal relationship where
there are one or more children of the relationship by birth or adoption.
• you and an individual have lived together in a conjugal relationship
continuously for the past one year, or Mail to:
• you have declared an individual to have a status equivalent to that of Student Aid Alberta, PO Box 28000 Stn Main, Edmonton, AB T5J 4R4
your common law partner under any law of Alberta or of Canada, or

Applicant’s Last Name Initials Social Insurance Number

J__ I__ I__ L

SPOUSE/PARTNER INFORMATION AND DECLARATION: (to be completed by Applicant’s spouse!partner)

Notice to Spouse/Partner: If you do not wish to include your personal information with the Applicant’s Application package,
you may submit a completed Schedule 2 separate from the Application to: Student Aid Alberta, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.

Spouse/Partner Information
Spouse/Partner Social Insurance Number

Spouse/Partner Last Name Spouse/Partner First Name

Spouse/Partner Birthdate Date spouse/partner completed/last attended regular High School

(excludes upgrading)
Day Month Year
Month Year
i I ' ■ I ____ l______ L_
J _______ L J _______ I_______ L

Have you lived in Alberta all your life? Q Yes □ No

If no, is Alberta the last province you have lived in for 12 consecutive months without being a full-time student? □ Yes □ No

Total income (Line 150 of 2013 Income Tax Return) (mandatory) (see Quick Tips p.13 #6) $

Spouse/Partner Income Status

□ Employed
□ Unemployed with income (WCB, El, etc.)
□ Assured Income for the Severely Handicapped (AISH)
□ Aboriginal Affairs and Northern Development Canada/Band Funds
□ Unemployed due to medical condition (Keep your doctor’s letter as this will be audited)
□ Unemployed no income

Spouse/Partner Gross Monthly Income $

Spouse/Partner Net Monthly Income (this amount must equal

the Spousal/Partner Net Income entered on Page 3)

Month Year
Date income starts
■ l I ___ L____ I____ I____

If your income will end during the Applicant’s study period, Month Year
indicate date
■ : I ___ I____ I____ I____
Spouse/Partner School Status
Will you be a full-time student at any time during the Applicant’s study period? Q Yes Q No

If yes, date you Day Month Year Date you Day Month Year
start school ■ l ■ ■ I __ I___ I____I___ end school l _ i— ^ - L I __ I___ I____I___
If both you and the Applicant are attending full-time studies, you should both complete a separate application form for student aid.

Signatures required on reverse side Page 263

Spouse/Partner Information 2014/2015 Schedule 2
Applicants who are Married or Common Law

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify the Applicant’s eligibility for financial assistance,
to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial
Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with FOIP.
The personal information may be disclosed to:
• federal, provincial or territorial government departments or agencies to verify any information the Applicant provided, determine
the eligibility of the Applicant for financial assistance and to administer student financial assistance programs.
• the federal government for use in research, statistical analysis and evaluations related to student financial assistance programs.
• Alberta Fluman Services to operate and administer provincial and federal student financial assistance programs, including your
eligibility, and the eligibility of the Applicant, for financial assistance.
• any municipal government department or agency, landlord, lending institution, credit bureau or employer to verify any information
the Applicant provided, to determine the eligibility of the Applicant for financial assistance and to administer student financial
assistance programs.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box
28000 Stn Main, Edmonton AB T5J 4R4.

Spousal/Partner Declaration:
• I declare that the information given on this Schedule is true and complete.

For the purpose of verifying the data provided in this Application for student financial assistance, I hereby consent to the release,
by Canada Revenue Agency to an official of Innovation and Advanced Education, of information from my income tax returns and, if
applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant
to and used solely for the purpose of determining and verifying the Applicant’s eligibility, entitlement for and the general administration
and enforcement of the student financial assistance programs under the Canada Student Loans Act, the Canada Student Financial
Assistance Act, the Students Finance Act (Alberta), the Student Loan Act (Alberta) and the Student Financial Assistance Act (Alberta).
This authorization is valid for the taxation year prior to the year of signature of this consent, the year of signature of this consent and
any other subsequent taxation year for which assistance is requested by the Applicant.

Signature of Spouse/Partner Today’s Date

Day Month Year

_ i _ l i l l I I !

Page 264
Concurrent Enrollment 2014/2015 Schedule 3
Exchange/Field Study Programs 14/15 S3
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify your eligibility for financial assistance, to administer (including
research, statistical analysis, and evaluations) and to enforce student financial assistance programs in accordance with the Student Financial
Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended from
time to time. The use and disclosure of your personal information is managed in accordance with FOIP. If you have any questions about the
collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Mail to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4

Applicant’s Last Name Initials Social Insurance Number

PART 1: CONCURRENT ENROLLMENT (see Quick Tips, p.13 #8)

Concurrent enrollment means you are simultaneously attending more than one school on a part-time basis
(less than 60% of a full-time course load at each education institution).
• If you are concurrently enrolled, enter your primary educational institution on Page 2 of this application
(Full-time Studies Information section)
• You must choose one of the institutions as your “primary institution”. Your primary institution will be responsible for confirming
your registration.
• Your course(s) at each school will be reviewed to determine whether you can be considered a full-time student for student
aid purposes.

Enter your primary institution:

Enter your additional institution(s):

_L _L _L _L _L I I I I I I

To verify full-time status, you must attach documents from your primary and additional institutions stating:
• Course Name(s)
• Course Weight(s)/Credit(s)
• Session Start and End Dates
• Course Costs

PART 2: EXCHANGE/FIELD STUDY STUDENTS ONLY

Enter your home educational institution:

Note: Your home institution is where tuition costs are paid and is also listed in the Full-time Studies Information section on Page 2
of this application.
Attach a letter of confirmation from your home institution or an acceptance letter from the host institution. Your letter should confirm
the actual start and end dates of your Exchange or Field Study Program and list your costs for Tuition, Mandatory Fees, and Books.

What is your airfare cost (if applicable)?

Page 265
Graduate Citizenship
Award
 Graduate Citizenship Award
The Graduate Citizenship Award recognizes graduate students who have demonstrated outstanding dedication and leadership to
fellow students and to their community.

Eligibility Criteria
Applicants must:
a. be a Canadian Citizen, Permanent Resident or international student,
b. be living in Alberta at the time of the application deadline,
c. be currently enrolled full-time (a minimum 60% course load) in at least one semester of study in a graduate
program at one of the four Alberta universities in the year of application, and
d. be involved at the university, municipal, provincial, national or international level or in non-profit community
organizations.

Applicants who are currently receiving an honorarium for serving on committees may apply.
An applicant cannot receive this award twice for the same service commitments used in a previously successful application.
International students must identify activities that contribute to the Alberta community.

Value of Award - $2,000

Fifty (50) Alberta Graduate Citizenship Awards are awarded each year to be divided among the following universities in Alberta:

The University of Alberta - 20 awards, The University of Calgary - 20 awards

The University of Lethbridge - 5 awards Athabasca University - 5 awards

Application Procedure
Complete the application form and include two letters of support, a personal resume, proof of Canadian Citizenship, Permanent
Resident, or international student visa, proof of Alberta residency and a confirmation of full-time enrollment. Please refer to the
Terms of Reference for more information on the selection process.

Submit the application form and supporting documents to the Graduate Student Association (GSA). Questions on the application
and evaluation process should be directed to the GSA at your institution.

The Graduate Student Association will forward the names of successful candidates to Alberta Scholarship Programs for processing.
The awards will be disbursed in December.

Information on other graduate awards administered by Alberta can be obtained at:

Alberta Scholarship Programs

Telephone: 780 427-8640
Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

Application Deadline is October 15

Page 267
 GRADUATE CITIZENSHIP AWARD
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and A
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under
the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the
collection of this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta,
T5J 4R4. Phone: 780-427-8640.
J

Return the completed form to the Graduate Student Association Office by October 15

Personal Information

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

First Name and One Initial (current legal name

City/Town

Previous Surname ____________

Area Code Telephone Number

Birth Date Gender (circle one) Alternate Telephone Number

iy month year

CITIZENSHIP (check one) Email Address:

CANADIAN CITIZEN or

PERMANENT RESIDENT (Landed Immigrant) or Have you lived in Alberta all your life? j Y j N
□ Note: Include a photocopy of permanent resident card.

INTERNATIONAL STUDENT
If no, since [
Month Year

□ N ote: Include a photocopy of your student visa.

POST-SECONDARY STUDIES
Name of Institution____________________

Student ID Number: Start Date of Program

V _______________________________________________________________________________________________________ J

April 2015

Page 268
r
Application Procedure
Complete the application form, and include the following:
Two (2) letters of support which addresses your service and community engagement efforts,
Curriculum Vitae which provides a brief description of your responsibilities associated with each activity,
*Proof of Canadian Citizenship or Permanent Resident Status such as a copy of birth certificate or passport, or
permanent resident card; copy of student visa if international student,
* Proof of Alberta residency - government issued ID, a third party lease agreement, a letter from an Alberta based
employer, a utility bill, etc. and,
*Confirmation of full-time enrollment.
V J

r Declaration of Applicant
" \

I have read and understand the instructions, and declare that:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic records may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for
an award,
b. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs and
for the use in research and statistical analysis and program evaluation, and
c. iff receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility and if I do not want to be identified I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Date (in ink)

V J

Information on other graduate awards is available at:

Alberta Scholarship Programs
Telephone: 780 427-8640
Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

Page 269
Federal/Provincial Grant for Post-Secondary Schedule 4
Students with Permanent Disabilities 2014/2015
1 4 /1 5 S4
INFORMATION AND INSTRUCTIONS

If you have a documented permanent disability and are attending post-secondary studies, you may be eligible to
receive more student aid. You will have to include medical documents with your first application.

What is a Permanent Disability?

A permanent disability is a functional limitation caused by a physical or mental impairment that restricts the ability of a person
to perform the daily activities necessary to participate in studies at a post-secondary level or labour force, and is expected to remain
with the person for the person’s expected natural life.

Before applying... Tips for completing your Schedule 4

Talk with a Disability Advisor at your school about your
educational goals and what kind of supports may already be in
place at your chosen institution.
What permanent disability student aid could I be
eligible for?
• Canada Student Grant for Students with Permanent
Disabilities: $2,000 per loan year to assist you with
education and living costs.
• If you apply for student aid online, you must still submit
a paper Schedule 4.
• Attach all required documentation to your Schedule 4.
• The Disability Advisor at your school may be authorized
to sign your Schedule 4. Check with the advisor first for
assistance and further instructions.
• If you are applying for a reduced course load, your
Schedule 4 must be signed by an official at your school.

• Canada Student Grant for Services and Equipment for

Students with Permanent Disabilities: Up to $8,000 per
loan year to help you with exceptional education related
costs such as assistive services or equipment.
• The Canada Student Grants program will cover a portion of
the cost of a Learning Assessment (up to a maximum of
$1,200 per loan year) if the assessment confirms you have
a learning disability.
When should I apply?
It is best to apply in early July for September study. You can
apply at any time of the year but Student Aid Alberta must
receive your application, including Schedule 4, at least
30 days before this year’s program ends in order to process it.
Do I need to keep receipts?
If you receive student aid for assistive services and equipment,
you must submit your receipts to Student Aid Alberta by the
end of your study period to show that the student aid you
received was used as intended. Write your Social Insurance
Number (SIN) and your name on each receipt.
If you do not use all of the student aid, you must return the
unused funds to Student Aid Alberta. Make your cheque or
money order payable to Government of Alberta. If you do not
send receipts or return the unused funds, you will be in an
overaward situation.
MAILING ADDRESS

What is a reduced course load? Student Aid Alberta

Your disability may limit you from taking a full course load. If Attention: Disability Grants
so, you can carry as little as 40% of a full course load and still PO Box 28000 Stn Main
apply for full-time student aid. Your Schedule 4 must be signed Edmonton AB T5J 4R4
by an official at your school to confirm that you are taking a
reduced course load. If you are studying part-time, you may
also be eligible for permanent disability funding. A part-time
application can be printed from studentaid.alberta.ca

APPLICANT AGREEMENT

If I receive a disability grant for services or equipment for post-secondary students with permanent disabilities, I hereby agree
to provide, by the end of my study period, receipts which will show that the student aid was spent for its intended purposes.
Include your name and Social Insurance Number on all receipts sent in.

Applicant’s Signature Today’s Date Telephone

Day Month Year

I I I I J___I___L
Page 270
 Schedule 4

INFORMATION AND INSTRUCTIONS - CONTINUED

What documents do I need to include?
You must include:
• An Application for Financial Assistance available
at studentaid.alberta.ca
• A Schedule 4
• Proof of your permanent disability - Medical documents
identifying your permanent disability and describing how it
restricts your ability to participate in post-secondary studies
must be submitted with your first application as a student with
a permanent disability. The documents may include:
- Copies of a medical letter
- A learning disability assessment, or
- A document proving you are in receipt of federal and/or
provincial disability assistance such as AISH
• An estimate of equipment costs - If you request funding for
equipment, you must provide an estimate of your equipment
costs. New estimates will be required each additional time
you request funding for equipment.
• Assessment fee - If an assessment confirms you have a
learning disability, you may be reimbursed for a portion of the
cost of this service. The date of the assessment must be no
earlier than six months before you start your studies. You must
supply a receipt showing that you paid for this service.
TIP: Check with the Disability Advisor at your school first.
They can provide information about assistive services
and equipment.

Summary of Disability Documentation Required

Type of Disability Documentation Required

• Audiologist report, or
Deaf, Hearing Impaired
• Letter from a physician with an explanation of the degree of hearing loss

• Specialist report, or
Blind, Visually Impaired
• Letter from a physician with a description of the functional limitations

• Psycho-educational report from a Psychologist, or

Learning Disability
• Neuro-psychological report

Speech • Speech language pathologist report

• Specialist report, or
Mobility/Agility Impairment • Letter from a physician with an explanation of the nature of the mobility/agility
impairment (functional limitation)

• Psychologist report, or
• Neuro-psychological report, or
ADD/ADHD
• Letter from a psychiatrist, or
• Letter from a physician with details about the diagnosis

• Psychologist report with a DSM diagnosis, or

Psychiatric or Psychological • Letter from a psychiatrist with a DSM diagnosis, or
• Letter from a physician with details about the diagnosis including the DSM

• Psychologist report, or
Autism, Asperger, Rett
• Letter from a physician with details about the diagnosis

• Neuro-Psychological report, or
Brain Injury/Cognitive Impairment
• Brain injury/cognitive impairment report/assessment

• Chronic Fatigue: a detailed letter from physician

Other Permanent Disability such as:
• Irlen Syndrome: assessment report from a certified Irlen Screener

Page 271
Federal/Provincial Grant for Post-Secondary Schedule 4
Students with Permanent Disabilities 2014/2015
1 4 /1 5 S4
Innovation and Advanced Education is collecting your personal information under the authority of section 33(c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and
Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid
Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta,
Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Applicant’s Last Name Initials Social Insurance Number

This schedule is complete only if all required documentation is submitted.

Before you start, read the information on the Information and Instructions pages.

You must submit a Schedule 4 if (check all that apply):

□ This is the first time you are applying as a student with a documented permanent disability, and/or
□ You are requesting assistive services and equipment (complete Sections 1, 2), and/or
□ You are enrolling in a reduced course load (your school must complete Section 3)

Start End
Enter your program session Day Month Year Day Month Year
start and end dates for the
2014/2015 school year. i i I J___ I___ I___ i i I J___ I___ I___

Learning Assessment Fee (see Information and Instructions)

Assistive Services
(Enter TOTAL amount for the 2014/2015 program session)

□ Note Taker/Scribe □ Interpreter (Oral, Sign, CART) $

□ Tutor □ (while
Educational Attendant Care
in school)
$

□ Academic Strategist □ (to and fromTransportation

Specialized
school only)

□ Reader □ Other Services $

$
2 . Equipment/Assistive Technology
[Check appropriate box(es) and provide two separate estimates]
(Enter the description and amount for the 2014/2015 program session)

□ Electronic Reading/Writing Software I i Assistive Devices for Hearing

$ $

□ Assistive Software Q Alternate Formats

$ $

□ Digital Recorder I \ Other Equipment

$ $

□ Assistive Devices for the Visually Impaired $

$
$
$

Page 272
Federal/Provincial Grant for Post-Secondary Schedule 4
Students with Permanent Disabilities 2014/2015

For Educational Institution Use ONLY - Do Not Write in this Area

3. Reduced Course Load (to be completed by the Disability Advisor or Financial Aid Officer or Registrar ONLY if you are enrolling in
between 40% to 59% of a full course load and want to be considered for full-time student aid)

What is the student’s percentage of a full course load? %

Signature of School Official Printed Name of School Official

Today’s Date (in in k ) Telephone

Day Month Year
J__ I__ I__ I__ L
J___ L J___ I___ L

For Use by Disability Advisor ONLY - Do Not Write in this Area

Nature of Permanent Disability [Please check appropriate box(es)]

Q Deaf, Hearing Impaired □

I I Blind, Visually Impaired □
I I Learning Disability □
I \ Speech □
l Mobility/Agility Impairment □ for definition of permanent disability)

Is disability permanent? Q No Q Yes

if not previously provided)

Attach documentation itemizing the assistive services

TOTAL recommended services/equipment
and/or equipment that covers the above.
Comments

Authorization Code Email Address of Disability Advisor

Signature of Disability Advisor (in ink) Name (please print)

Today’s Date (in ink) Telephone Extension

Day Month Year
J__ l__ I__ I__ I__ L
I I ! I J___ I___ L

Page 273
v _y d l ld U .d
Federal/Provincial Grant for Post-Secondary
students with Permanent Disabilities 2015/2016
,
« . . . . Student Aid Alberta
Schedule 4
15/16 S4
Information and Instructions

If you have a documented permanent disability and are attending post-secondary studies, you may be eligible to receive more
student aid. You must include medical documents with your first application.

What is a Permanent Disability?

A permanent disability is a functional limitation caused by a physical or mental impairment that restricts the ability of a person
to perform the daily activities necessary to participate in studies at a post-secondary level or labour force, and is expected to remain
with the person for the person’s expected natural life.

Before applying... Tips for completing your Schedule 4

Talk with a Disability Advisor at your school about your
educational goals and what kind of supports may already be in
place at your chosen institution.
What permanent disability student aid could I be
eligible for?
• Canada Student Grant for Students with Permanent
Disabilities: $2,000 per loan year to assist you with
education and living costs.
• If you apply for student aid online, you must still submit
a paper Schedule 4.
• Attach all required documentation to your Schedule 4.
• The Disability Advisor at your school may be authorized
to sign your Schedule 4. Check with the advisor first for
assistance and further instructions.
• If you are applying for a reduced course load, your
Schedule 4 must be signed by an official at your school.

• Canada Student Grant for Services and Equipment for

Students with Permanent Disabilities: Up to $8,000 per
loan year to help you with exceptional education related
costs such as assistive services or equipment.
• The Canada Student Grants program may cover up to 75%
of the cost of a Learning Assessment (up to a maximum of
$1,200 per loan year) if the assessment confirms you have
a learning disability.
When should I apply?
It is best to apply in early July for September study. You can
apply at any time of the year but Student Aid Alberta must
receive your application, including Schedule 4, at least
30 days before this year’s program ends in order to process it.
Do I need to keep receipts?
If you receive student aid for assistive services and equipment,
you must submit your receipts to Student Aid Alberta by the
end of your current study period to show that the student aid
you received was used as intended. Write your Social Insurance
Number (SIN) and your name on each receipt.
If you do not use all of the student aid, you must return the
unused funds to Student Aid Alberta. Make your cheque or
money order payable to Government of Alberta. If you do not
send receipts or return the unused funds, you will be in an
overaward situation.
Upload or Mail Your Form

What is a reduced course load? Send documents electronically* Mailing Address

Your disability may limit you from taking a full course load. If 1. Visit studentaid.alberta.ca Student Aid Alberta
so, you can carry as little as 40% of a full course load and still 2. Sign in via SFS Login Attention: Disability Grants
apply for full-time student aid. Your Schedule 4 must be signed 3. Submit securely using PO Box 28000 Stn Main
by an official at your school to confirm that you are taking a e-Document Upload Edmonton AB T5J 4R4
reduced course load. If you are studying part-time, you may "For assistance: e-Doc Upload FAQ
also be eligible for permanent disability funding. A part-time
application can be printed from studentaid.alberta.ca

Applicant Agreement

If I receive a disability grant for services or equipment for post-secondary students with permanent disabilities, I hereby agree to
provide, by the end of my current study period, receipts which will show that the student aid was spent for its intended purposes.
Include your name and Social Insurance Number on all receipts sent in.

Applicant’s Signature Today’s Date Telephone

Day Month Year
.............................................................................. .... ,
__ i___i___L ___1___1__ r a g itr274
 Schedule 4

Information and Instructions - Continued

What documents do I need to include?
You must include:
• An Application for Financial Assistance available
at studentaid.alberta.ca
• A Schedule 4 (submit if this is your first application
or if you are requesting services and equipment)
• Proof of your permanent disability - Medical documents
identifying your permanent disability and describing how it
restricts your ability to participate in post-secondary studies
must be submitted with your first application as a student with
a permanent disability. The documents may include:
- Copies of a medical letter
- A learning disability assessment, or
- A document proving you are in receipt of federal and/or
provincial disability assistance such as AISH
• An estimate of equipment costs - If you request funding for
equipment, you must provide an estimate of your equipment
costs. New estimates will be required each additional time
you request funding for equipment.
• Assessment fee - If an assessment confirms you have a
learning disability, you may be reimbursed up to 75% of the
cost of this service (up to a maximum of $1,200 per loan year).
The date of the assessment must be no earlier than six months
before you start your studies. You must supply a receipt
showing that you paid for this service.
TIP: Check with the Disability Advisor at your school first.
They can provide information about assistive services
and equipment.

Sum m ary of Disability D ocum entation Required

Type of Disability Documentation Required

• Audiologist report, or
Deaf, Hearing Impaired
• Letter from a physician with an explanation of the degree of hearing loss

• Specialist report, or
Blind, Visually Impaired
• Letter from a physician with a description of the functional limitations

• Psycho-educational report from a Psychologist, or

Learning Disability
• Neuro-psychological report

Speech • Speech language pathologist report

• Specialist report, or
Mobility/Agility Impairment • Letter from a physician with an explanation of the nature of the mobility/agility
impairment (functional limitation)

• Psychologist report, or
• Neuro-psychological report, or
ADD/ADHD
• Letter from a psychiatrist, or
• Letter from a physician with details about the diagnosis

• Psychologist report with a DSM diagnosis, or

Psychiatric or Psychological • Letter from a psychiatrist with a DSM diagnosis, or
• Letter from a physician with details about the diagnosis including the DSM

• Psychologist report, or
Autism, Asperger, Rett
• Letter from a physician with details about the diagnosis

• Neuro-Psychological report, or
Brain Injury/Cognitive Impairment
• Brain injury/cognitive impairment report/assessment

• Chronic Fatigue: a detailed letter from physician

Other Permanent Disability such as:
• Irlen Syndrome: assessment report from a certified Irlen Screener

Page 275
 Federal/Provincial Grant for Post-Secondary
Canada Students with Permanent Disabilities 2015/2016 ^A ^O w bC yJl
Student Aid Alberta
Schedule 4
15/16 S4
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and
Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid
Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta,
Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.
Applicant’s Last Name Initials Social Insurance Number

This schedule is complete only if all required documentation is submitted.

Before you start, read the information on the Information and Instructions pages.

You must submit a Schedule 4 if (check all that apply):

□ This is the first time you are applying as a student with a documented permanent disability, and/or
□ You are requesting assistive services and equipment (complete Sections 1, 2), and/or
□ You are enrolling in a reduced course load (your school must complete Section 3)

Start End
Enter your current study period Day Month Year Day Month Year
start and end dates for the
2015/2016 school year. i i I J___ I___ I___ i i I J___ I___ I___

Learning Assessment Fee (enter 75% of the cost up to a maximum of $1,200)

1. Assistive Services
(Enter TOTAL amount for the current study period)

□ Note Taker/Scribe $ I i Interpreter (Oral, Sign, CART)

□ Tutor (with specific □ Educational Attendant Care

course knowledge) (while in school)
□ Specialized Transportation
□ Academic Strategist (to and from school only)

□ Reader Q Other Services $

$
2. Equipment/Assistive Technology
• Check appropriate box(es) and provide one estimate
• Enter the description and amount for the current study period

Electronic Reading/Writing Software □ Assistive Devices for Hearing

$ $

□ Assistive Software I \ Alternate Formats

I \ Other Equipment
$
$
$
$

Page 276
Federal/Provincial Grant for Post-Secondary Schedule 4
Students with Permanent Disabilities 2015/2016

For Educational Institution Use ONLY - Do Not Write in this Area

3. Reduced Course Load (to be completed by the Disability Advisor or Financial Aid Officer or Registrar ONLY if you are enrolling
in between 40% to 59% of a full course load and want to be considered for full-time student aid)

What is the student’s percentage of a full course load? %

Signature of School Official Printed Name of School Official

Today’s Date (in ink) Telephone

Day Month Year
___I___I_ I J ___I___I___I___I___I___I___
___ i___ I___ i___ i___ ___ I___ I___ I___

For Use by Disability Advisor ONLY - Do Not Write in this Area

Nature of Permanent Disability (Documentation regarding the nature of permanent disability must be attached if not previously provided.)
Please check appropriate box(es):
I I Deaf, Hearing Impaired □
j Blind, Visually Impaired □
I I Learning Disability □
I \ Speech □
I I Mobility/Agility Impairment □
for definition of permanent disability)

Is disability permanent? (O) Yes (2 No

Attach documentation itemizing the assistive services
TOTAL recommended services/equipment
and/or equipment that covers the above.
Comments

Authorization Code Email Address of Disability Advisor

I I I I I

Signature of Disability Advisor (in ink) Name (please print)

Today’s Date (in ink) Direct Telephone Number Extension

Day Month Year
I I I I I
J___ L J___ I___ L

Page 277
The Helen and George
Kilik Scholarship

b e tb c ^M
Page 278
 The Helen and George Kilik Scholarship
This scholarship was established in 1997 as an endowment by the family of Mr. and Mrs. Kilik with the Alberta Heritage
Scholarship Fund. The purpose of the scholarship is to assist a student from Olds High School pursue post-secondary studies
and establish himself in a career.

Award Amount - $1,000

Eligibility Criteria
The applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided
in Alberta during the qualifying grades,
b. have completed all high school grades at Olds High School,
c. be in financial need
d. be involved in extra-curricular activities,
e. demonstrate academic achievement particularly in mathematics and science, and
f. intend to pursue post-secondary studies.

Selection Procedure
The recipient will be selected by a selection committee at Olds High School

Application Procedure

Complete the application form and submit to the main office at Olds High School

F o r m ore inform ation contact:

Alberta Scholarship Programs
Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.gov.ab.ca/scholarships

Applicants will be notified of the status of their application in September. The award will be issued in November after
Alberta Scholarship Programs confirms the recipient’s full-time enrollment in post-secondary studies.

Application Deadline: July 1

Page 279
 Helen and George Kilik Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
ofPrivacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required fo r processing)

Last Name (c u rre n t fu ll legal nam e) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll legal nam e)

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M F day month year
____ i____ ____ I____ ____ L _ __I____ I____

Have either of your parents obtained a university degree? Y N

CITIZENSHIP (check one)

C A N A D IA N C IT IZ E N or I I PERM ANENT R E S ID E N T (L a n d e d Im m ig ra n t)

□
ALBERTA RESIDENCY
'----------- ' Note: AAttach a nphotocopy
tta ch a off nerm
h n t iv n n v o permanent
anent resident rarH
card norr im
immigration long fform. Visa students are not eligible.
m io ra fin n lnno

Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
N

Have you lived in Alberta all your life?

If you answered “ N o ” to either of these questions, please indluce a letter
N Since month year explaining your residency.
__I__ I 1___ L

PROPOSED POST-SECONDARY STUDIES

Name of Institution

Institution City Entry Date of Program Name of Program

| mojith | | yepr

Did you attend all of your high school at Olds High School? Yes | | No

Office Use Only

65 8 8 8 1 2

GRANT TO TAL AW D IN S T IT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t

MO YR A U T H O R IZ A T IO N AW ARD KEY A PP KEY

Revised: January 2013

Page 280
To be completed by the Selection Committee:

The individual in this application has been selected to receive the Helen and George Kilik Scholarship.
The award will be presented on at
Date Location
Verified by:
Name of Principal

Signature Date

Highlights of the Recipient’s Accomplishments

Declaration of Applicant:

I understand and agree that if I receive a scholarship my name, award and city/town may be released publicly to promote
the program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta
Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Page 281
Alberta Award for the Study of
Canadian Human Rights and
Multiculturalism
 ALBERTA AWARD FOR THE STUDY OF CANADIAN HUMAN RIGHTS AND
MULTICULTURALISM

In recognition of Alberta’s centennial and the contributions and experiences of our diverse population, the Minister of Alberta
Community Development established the Alberta Award for the Study of Canadian Human Rights and Multiculturalism. This award
is funded through an endowment by the Human Rights Education and Multiculturalism Fund and is administered jointly by Alberta
Justice and Solicitor General and Alberta Enterprise and Advanced Education.

This award supports graduate studies in Canadian human rights or multiculturalism. Graduate students attending an Alberta public
post-secondary institution whose studies will contribute to the advancement of human rights and multiculturalism are encouraged to
apply.

Two awards of $10,000 are available each year. One for a student studying at the Master’s level and one for a student studying at
the Doctoral level. The Master’s level award honours one of Alberta’s human rights champions and is known as the Pardeep Singh
Gundara Memorial Scholarship.

Purpose
To encourage graduate studies that will create value for Albertans by promoting informed thinking about Canadian human rights,
cultural diversity, and multiculturalism. To support the pursuit of studies in Canadian human rights, cultural diversity, and
multiculturalism, and building capacity to undertake human rights or multicultural work in Canada.

Eligibility Criteria

Applicant must be:

• a Canadian citizen or a Permanent Resident,
• enrolled or plan to enroll as a full-time graduate student (Master’s or Doctoral level) at an Alberta public post-secondary
institution,
• enrolled or plan to enroll in a program of study that supports the purpose of the scholarship, and
• planning to do research that is within a Canadian context and will ultimately benefit Albertans.
Note: The scholarship is not open to students pursuing post-graduate studies.

Selection Procedures
The selection committee will consider each applicant’s information as provided on the application form, the essay, and curriculum
vitae. The essay, however, is the most important component of the application and has the greatest impact on the committee’s
decision.

All applicants will be notified of the result of the competition in May.

Successful applicants may expect to receive their award in October, after Alberta Scholarship Programs confirms their enrollment in
graduate studies.
h'AXLD APPLICATIONS ARE NO 7 ACCUP TED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Application Deadline: February 1

Page 283
 ALBERTA AWARD FOR THE STUDY OF CANADIAN HUMAN RIGHTS
AND MULTICULTURALISM
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to detennine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please phone Alberta Scholarship Programs at 780.427.8640.

Personal Inform ation

You m ay use the Learner R egistry at w w w .e d u c a tio n .g o v .a b .ca to fin d y o u r A lbe rta Student N um ber o r to have one assigned

Alberta Student Number (required fo r processing) Social Insurance Number (required fo r processing)

Last Name (cu rre n t fu ll leg a l nam e) Please use u p p e r and lo w e r case. First Name and One Initial (c u rre n t fu ll leg a l nam e)

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M mjinth
____ i yT i____

CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)

Note: Include a photocopy of your permanent resident card. Visa students are not eligible.

Education Information:
Name of post-secondary institution in Alberta you will be attending this fall:
Name of program --------------------------------------------------------------------
Date you will be completing the program month/year):--------------------------

What degree will you obtain? -------------------------------------------------------

What is your major? ------------------------------------------------------------------
What is your thesis or project title?--------------------------------------------------

Office Use Only

00

00

00

78 1 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t E

MO YR AUTHORIZATION AW ARD KEY APP KEY

Revised: May 2013

Page 284
 Essay
The essay is the most important component of the application. Please address the following points in your essay:

1. What are the questions (up to three) you want to explore in your study? Why are they important to you?
2. How will your studies create value for Albertans in the areas of human rights, diversity or multiculturalism?
3. How do you plan to integrate the academic and professional literature about the topic of your study with your own
experiences and perspectives?
4. If your study involves human subjects, how many will be tested/interviewed, etc.
5. What is the likely impact of your research project in Alberta?
6. How do you propose to study the issues and what methodology will you be using to study these issues?

The essay should be no more than 1,200 words, double spaced, no more than six lines per inch, with a minimum font
size of 10. Condensed type is not acceptable.

Application & Selection Procedure

Include with the original application, your essay and curriculum vitae.

The essay is the most important component of the application and has the greatest impact on the committee’s decision. Please feel
free to consult your academic advisor.

Mail the complete package to Alberta Scholarship Programs no later than February 1.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my post-secondary academic progress and enrollment status may be released and
exchanged by and between Alberta Scholarship Programs and the education institution.
b. personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs
and for the use in research and statistical analysis in program promotion.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not
a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

For information on other awards administered by Alberta Scholarship Programs visit:

alis.alberta.ca/scholarships

Page 285
^ d b e * b f iji Application for Interest Free Status
for a person on Parental Leave
S tu d e n t A id A lb e r ta
Service Centre
for Alberta Student Loans*
*For definition of Alberta Student Loan, see bottom of Instruction Sheet

Instruction Sheet
Complete this Application for Interest Free Status if you are a student who is taking a break
from full-time or part-time studies for parental leave.

What do you have to do?

■ Carefully read the information on the application.
■ Complete your name, Social Insurance Number, address and phone number.
■ Identify the Qualifying Event for parental leave as described on the application and provide the
applicable documents.
■ Indicate the date of the Qualifying Event.
■ Indicate your last day of attendance in full-time or part-time studies. Be sure to notify your school of
your last day of attendance (withdrawal date).
■ Read, sign and date the Applicant Declaration on Page 2.
■ Have your spouse/partner read, sign and date the Spouse/Partner Declaration on Page 2 if the
spouse/partner is providing documents in support of the Applicant’s request for interest-free status.
Where do I send the application?
■ First, make a copy for your records.
■ Send the original application to: Student Aid Alberta Service Centre
PO Box 4050
Mississauga STN A
Mississauga ON L5A 4M9
Who do I contact for help?
Student Aid Alberta Service Centre
■ 1-855-606-2096 toll free from anywhere in North America
■ 1-855-306-2240 TTY for the hearing impaired
■ 800 2 529-9242 outside North America (add the appropriate International Access Code)

‘ Definition of Alberta Student Loan

“Alberta Student Loan” collectively means all loans made to the Student from time to time pursuant to the
S tudents Finance A ct (Alberta), the S tudent Loan A c t (Alberta) and the S tudent Financial Assistance A ct
(Alberta), and any regulations made under these Acts, each as may be amended from time to time
(“Alberta Student Finance Acts”), including loans made to the Student by the Minister, loans made to the
Student by a financing institution and transferred to the Minister, loans made while the Student was a
minor, and also including any grant overpayments converted to a loan by the Minister under the Alberta
Student Finance Acts.

June 2014

Page 286
 Application for Interest Free
^ A ilo e ib C y J i Student A id Alberta Status for a person on
Service Centre
Parental Leave
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for parental leave interest free status for Alberta
Student Loans in accordance with the Student Financial Assistance Act (Alberta) as may be amended from time to time. The use and disclosure of
your personal information is managed in accordance with the Freedom of Information and Protection of Privacy Act (Alberta). If you have any
questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from
anywhere in North America. You can also mail your questions to the Student Aid Alberta Service Centre, Executive Customer Assistance
Department, PO Box 4050, Mississauga Stn A, Mississauga ON L5A 4M9.
APPLICANT’S NAME ADDRESS and PHONE NUMBER

WHAT IS INTEREST FREE STATUS for a person on PARENTAL LEAVE?

A student who takes a break from full-time or part-time studies for parental leave may apply for interest free status on
their Alberta Student Loan(s)* (*see definition on the Instruction Sheet). The interest free status begins on the
last day of attendance at school and lasts up to a maximum of 12 months from that date.
WHO IS ELIGIBLE?
A person is eligible for interest free status due to parental leave when they cease to be a full-time or part-time student
in order to give birth to, care for or support a child who is a new addition to the family by reason of one of the
Qualifying Events listed in the chart below, and intend to return to full-time or part-time studies. The Qualifying Event
must have happened within 12 months of when you ceased to be a full-time or part-time student.
FOR WHICH LOANS CAN I GET INTEREST FREE STATUS?
This only applies to your Alberta Student Loan(s). You will still be required to make payments on your Canada
Student Loan(s) and any other loans issued by another province.

HOW TO APPLY
1. Identify your Qualifying Event for parental leave and attach copies of the documents indicated:
check Qualifying Definition Attach copies of the following
applicable
V Event documents
Parent-to-be You or your spouse/partner is Copy of the medical certificate confirming
expecting the birth of a baby. pregnancy and estimated date of birth.
Parent-by birth You or your spouse/partner has Copy of one of the following:
given birth and you are the a) birth certificate (long version)
biological mother or father of this b) Blue Cross form
baby. c) hospital form
d) Canada Child Tax Benefit stub
Parent-by- You have been granted adoption Copy of the adoption order issued by the
adoption of a child by the courts. courts.
Legal Guardian You have been appointed legal Copy of the guardianship order issued by the
guardian of a child. courts or other proof of guardianship
acceptable to the Minister.
Step Parent or You have become a person Copy of the child's birth certificate and a copy
Foster Parent standing in place of a parent. of one of the following (as applicable):
a) your marriage certificate
b) adult interdependent partnership agreement
c) statutory declaration declaring your
responsibility for the child
d) other documentation acceptable to the
Minister

2. Indicate the date of the Qualifying Event: month year

3. Indicate your last day of attendance in full-time
or part-time studies: day month year

Signatures required on page 2 Page 1 of 2

June20^|g e 287
 Application for Interest Free Status
for a person on Parental Leave
for Alberta Student Loans
APPLICANT’S NAME SOCIAL INSURANCE NUMBER

APPLICANT DECLARATION
I declare and warrant that:
• the information that I have provided in this Application, and
any additional information that I have provided to Innovation
and Advanced Education in respect of this Application is true
and complete, and I understand it is subject to audit.
I agree to:
• immediately notify Innovation and Advanced Education in
writing of any change to any information contained in this
Application.
• provide information or documents as requested by
Innovation and Advanced Education to verify any statements
made in this Application.
I understand that my personal information may be
disclosed and exchanged:
• by and between Innovation and Advanced Education and
any other federal, provincial or territorial government
department or agency, educational institution, or financial
institution to verify any information I have provided to
Innovation and Advanced Education and to determine my
eligibility for the parental leave interest free status.
• by and between Innovation and Advanced Education, the
federal government and the educational institution(s) named
in my application(s) for financial assistance, for use in
research, statistical analysis, and evaluations related to
student financial assistance programs.
I understand that:
• I must submit this Application and provide evidence of one
of the Qualifying Events within 12 months from the date of
my withdrawal from full-time or part-time studies, to be
assessed for eligibility for interest free status due to parental
leave.
• I will be expected to start repayment of my Alberta Student
Loans, as required, if I do not return to full-time or part-time
study at the end of my parental leave.
• I may be denied parental leave interest free status if I fail to
provide the documents or information as requested by
Innovation and Advanced Education to verify statements
made in this Application.
• if I make a false or misleading statement in this Application,
or fail to disclose information as requested by Innovation and
Advanced Education, I may be denied financial assistance,
including parental leave interest free status and/or required to
immediately repay all financial assistance received, and/or
subject to criminal prosecution.
• failure to disclose information or provide updated
information as requested by Innovation and Advanced
Education may constitute the making of a false or misleading
statement.
• Innovation and Advanced Education has the right to recover
benefits I receive that I am not entitled to, including any due
to administrative errors.

I have read the Applicant Declaration and I confirm that the Applicant Declaration applies to the information that I have provided in
this Application and to any additional information that I may subsequently provide to Innovation and Advanced Education in respect
of this Application.

Signature of Applicant (sign in ink) Date (in ink)

SPOUSE/PARTNER DECLARATION
(Complete only if you are providing documents in support of the Applicant’s request for interest-free status.)

For the purpose of verifying the data provided in my Spouse/Partner’s Application for Parental Leave Interest Free Status,
■ I declare that the information included on this Application and any additional information that I have provided to Innovation
and Advanced Education in respect of this Application is true and complete.
■ I understand that my personal information will be disclosed and exchanged by and between Innovation and Advanced
Education and any other federal, provincial or territorial government department or agency, or educational institution, or
financial institution to verify my personal information included on this form, and to determine my spouse’s/partner’s eligibility
for parental leave interest free status.
■ I understand that my personal information will be disclosed and exchanged between Innovation and Advanced Education
and the federal government, and by Innovation and Advanced Education and the federal government, for use in research,
statistical analysis, or evaluations related to student financial assistance programs.

I have read the Spouse/Partner Declaration and I confirm that the Spouse/Partner Declaration applies to the information that I have
provided in this Application and to any additional information that I may subsequently provide to Innovation and Advanced
Education in respect of this Application.

Signature of Spouse/Partner (sign in ink) Date (in ink)

Page 2 of 2
June^ l 288
 Student Aid Alberta
Service Centre

Declaration for Interest Free Status for Alberta Student Loans*

for a Step Parent on Parental Leave
*For definition of Alberta Student Loan, see bottom of Instruction Sheet.

Instruction Sheet
If within the last twelve months:
(a) you have taken a break from full-time or part-time post-secondary studies;
(b) you are responsible for the care or support of a child(ren);
(c) you are not the biological parent, adoptive parent, or legal guardian of the child(ren) and you do
not have a legal document evidencing your responsibility for the child(ren); and
(d) you want to apply for interest free status for your Alberta Student Loans as a person on
parental leave;

you need to print and complete the attached Declaration.

In completing the Declaration for Interest Free Status for Alberta Student Loans for a Step Parent on
Parental Leave (“Declaration”) you must identify the child(ren) that you became responsible to care for or
support. Describe how this responsibility arose. This responsibility must have arisen within 12 months of
when you ceased to be a full-time or part-time student.

Steps to complete the Declaration:

1) Print off the Declaration and complete it in ink.
2) Complete your legal name, city or town, and province/state.
3) Complete the child(ren)’s legal name. (This is the child(ren) you became responsible to care for or
support within 12 months of when you ceased to be a full-time or part-time student.)
4) Describe the nature of your responsibility to care for or support this/these child(ren) and how this
responsibility arose.
5) Provide the date you became responsible to care for or support this/these child(ren).
6) You need to send the original Declaration to the Student Aid Alberta Service Centre. It is recommended
that you make at least one copy for your records.
7) Keep one copy in a secure place for your records.

Where do I send the Declaration?

Send the original Declaration to:
Student Aid Alberta Service Centre, PO Box 4050, Mississauga STN A, Mississauga ON L5M 4M9

Who do I contact for help?

Student Aid Alberta Service Centre
• 1-855-606-2096 toll free from anywhere in North America
• 1-855-306-2240 TTY for the hearing impaired
• 800 2 529-9242 outside North America, plus appropriate International Access code

*Definition of Alberta Student Loan

“Alberta Student Loan" collectively means all loans made to the Student from time to time pursuant to
the Students Finance Act (Alberta), the Student Loan Act (Alberta) and the Student Financial
Assistance Act (Alberta), and any regulations made under these Acts, each as may be amended from
time to time (“Alberta Student Finance Acts”), including loans made to the Student by the Minister,
loans made to the Student by a financing institution and transferred to the Minister, loans made while
the Student was a minor, and also including any grant overpayments converted to a loan by the
Minister under the Alberta Student Finance Acts.

Jan 2014
Page 289
 ^4dbetbfijmStudent Aid Alberta
Service Centre Declarant’s (Student’s) Social Insurance Number:

Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for parental
leave interest free status for Alberta Student Loans as a person who is responsible for the care of a child(ren) but is
not the biological parent, adoptive parent or legal guardian in accordance with the Student Financial Assistance Act
(Alberta) as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with the Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions about
the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-
2096 from anywhere in North America. You can also mail your questions to the Student Aid Alberta Service Centre,
Executive Customer Assistance Department, PO Box 4050, Mississauga Stn A, Mississauga ON L5A 4M9.

Declaration for Interest Free Status for Alberta Student Loans for a
Step Parent on Parental Leave
I,____________________________________________o f____________________________
(Declarant’s (Student's) Full Legal Name) (City/Town)

in the Province/State o f_________________________________, declare that I am responsible

for the care of or support of the following child(ren) who is/are a new addition to my family within
the past 12 months (add an additional sheet to this Declaration if required),
Legal Name of child_____________________________________________________
Legal Name of child_____________________________________________________
Legal Name of child_____________________________________________________

and my responsibility for the care or support of this/these child(ren) is as follows:

and this responsibility arose as of

(Date)
I understand that if I make a false or misleading statement, I may be denied financial
assistance, and/or be required to immediately repay all financial assistance received, and/or be
subject to criminal prosecution.

Declarant’s (Student’s) Signature Date

Jan 2014
Page 290
International Education
Awards Ukraine

1yQlberbtkm
Page 291
 International Education Awards - Ukraine
This program was designed to enable post-secondary students, post-graduates, professionals and scholars to undertake
career-related training, research or study in Ukraine, and Ukrainian post-secondary students, post-graduates, professionals
and scholars to undertake career-related training, research or study in Alberta.

The bursary was created in 2003 with a $500,000 endowment in support of the Alberta Innovation and Advanced
Education’s international education strategy.

Eligibility Criteria

Canadian Citizens/Permanent Residents: Applicants must be Alberta residents, preferably attending or associated with
an Alberta post-secondary institution or apprenticeship/co-op program. Applicants must be either enrolled in a post­
secondary institution at a senior level, a graduate student, a recent post-graduate, or a professional or scholar. Students
applying to take a course or applying to study for one or two semesters at a post-secondary institution in Ukraine are also
eligible.

Ukrainian residents: Applicants must be citizens or residents of Ukraine, preferably attending or associated with a post­
secondary teaching or research institution or apprenticcship/co-op program. Applicants must be either enrolled in a post­
secondary institution at a senior level, a graduate student, a recent post-graduate, or a professional or scholar. Students
applying to take a course or applying to study for one or two semesters at a post-secondary institution in Alberta arc also
eligible.

Selection Procedure
Recipients will be selected by a selection committee with two individuals representing Alberta post-secondary institutions
and two individuals from the Alberta Ukrainian community. Selection will be based on academic merit, past
accomplishments, the purpose or validity of the proposal, reference letter, and institutional support and benefit to the
recipient’s institution.

Please refer to the Terms of Reference posted on the website for selection and scoring details.

Up to five awards of $5,000 (Canadian funds) are available each year.

Application Procedure

Include with your application a resume/cv, an official transcript, an essay describing the program or research, a letter of
support from the host institution and a letter of reference.

Incomplete applications will not be submitted to the committee.

Submit completed application to:

Alberta Scholarship Programs

Faxed A pplications are not Accepted

Mail to: Courier to:

Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1

All supporting documents must be in English. All

translated information must be certified.

For information on this award and other scholarships contact:

Telephone: 780.427.8640
E-mail: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

APPLICATION DEADLINE IS FEBRUARY 1

 INTERNATIONAL EDUCATION AWARDS - UKRAINE

W c arc co llectin g th e personal in fo n n atio n on th is form u n d er the authority o f Section 33(c) o f the F reedom o f In form ation a n d P rotection o f P riva cy
A c t (F O IP A ct), as b ein g directly related to an d n ecessary to d eterm ine y o u r eligibility for a scholarship u n d er the A lb erta H erita g e S c h o la rsh ip A c t an d to
ad m in ister th e A lb erta S cholarship P rogram s. I f y o u h av e an y q u estio n s about the collection o f this inform ation, p lease co n tact A lb erta S ch o larsh ip P rogram s,
4th Floor, 9 9 4 0 106 S treet, E dm onton, A lberta, T 5 K 2V1 P hone 780.427.8640.

Personal Information
Social Insurance Number (Albertans only)

CITIZENSHIP (check one)

] CANADIAN CITIZEN
□ CITIZEN OF UKRAINE PERMANENT RESIDENT
Note: Attach a photocopy of permanent
resident card or immigraation long form.
Place of Birth

Have you lived in Alberta or Ukraine all your life | [YES | |NO If no. since (M onth. Year)

Gender circle one) Birthdatc (Day, Month, Year) E-Mail Address

M F
___I___ I___ I___I___ I___ I___ I___

Please ensure your application is complete and submitted by February 1.

Application must include a resume/cv, an official transcript, an essay describing the program or
research, a letter of support from the host institution and letter of reference.
All documents must be in English.

Office Use Only

Revised: June 2013

Page 293
 Proposed Program

What type of program will you be enrolled in?

j Internship | | Co-Op | | Practicumj | Apprenticeship | | Research | | Other

Name of the receiving institution (i.e. the school you plan on attending) Proposed program start date

___1______ 1___ ___l___1___l___

Address of the host institution Proposed program end date

___1______ 1___ ___1___1___1___

Name of person coordinating your program at the host institution Telephone Number

Include a letter of support from the above mentioned institution.

Additional Supporting Documents

S ta te m e n t o f In te n t/E s s a y :
In two pages or less, please provide a detailed description of your proposed program of study or research project and how your
internship, practicum, co-op program, research project or program could benefit Ukraine and Alberta. Also, include what you
plan to accomplish during and after your studies.

R e fe re n c e :
Please attach a reference letter which should comment on your academic record and assessment of the merits of the proposal or
program. The reference should be from an individual who is familiar with your academic career and must include the name,
title/position, address, telephone number and email address of the individual providing the reference.

E d u c a tio n In fo rm a tio n :
Please attach a one page educational resume listing schools you have attended and programs taken, including degrees,
diplomas, and certificates earned. Attach your most recent transcript or statement of marks and a letter indicating the
involvement and support for the program or project from the host institution.

Declaration of Applicant

I H AVE R E A D A N D U N D E R S TA N D TH E IN S TR U C TIO N S , A N D D E C L A R E THAT:

a. all information provided is true and complete, and 1 understand it is subject to audit,
b. I will be a student taking the intemship/co-op/practicum/apprcnticeship described above or conducting research.
c. I will notify the office of Alberta Scholarship Programs in writing if I withdraw before completing my program.

I U N D ER STAN D A N D A G R E E THAT:
a. personal information pertaining to my program enrolment status may be released and exchanged by and between Alberta
Scholarship Programs and the educational institution for the purpose of determining my eligibility for a scholarship, and
b. if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Janet and Horace Allen
Science Scholarship

_/4tbetbc^M Page 295

 Janet and Horace Allen Science Scholarship
This scholarship was established by the family of Janet and Horace Allen through the Alberta Heritage Scholarship Fund Endowment
program.

The scholarship recognizes the academic excellence of a student from Crowsnest Pass High School for their accomplishements in the
sciences.

Award Value - $1,500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Crowsnest Pass High School after September 1, 1995,
c. be enrolled or planning to enroll full-time in a post-secondary program, and
d. have the highest average of the eligible courses in Grade 12.
Biology 30 Chemistry 30
Physics 30 Science 30

Selection Procedure
The applicant with the highest average in tw o of the following Grade 12 courses will receive the award:

Application Procedure

Submit completed application form to Alberta Scholarship Programs.

Students will be notified of the status of their application in September and the awards are issued in November after Alberta
Scholarship Programs confirms full-time enrolment of the successful candidates.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to
achieve their fullest potential.

Application Deadline: June 1

 Janet and Horace Allen Science Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower ( First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) City/Town

P rev io us S u rn a m e
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M <)ay | m^nth | [ yepr ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Y N Y N month year
____ I____ ____ I____ I____ I____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? | | Yes, what year__________ | | No

Are you a student at Crowsnest Pass High School?

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month | year month I year
____i____ ____ i____i____ i____
Institution City Length of Program Year of Program
1^1 2nd 3rd 4lh

Office Use Only

56 8 8 8 1 2

GRANT TO TAL AW D IN S T IT PGM MO YR MO YR ORG ADD

Disbursement

MO YR A S P A U T H O R IZ A T IO N AW AR D KEY APP KEY

Revised: March 2013

Page 297
 Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if 1 do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
If your institution code is not listed here, check the institution code listing at www.alis.alberta.ca/ndf/scholarshins/codes.Ddf.

University of Alberta.................... ...2201
University of Calgary................... ...2202
University of Lethbridge.............. ...2203
NAIT....' ......................7 ................... ...2221
SAIT............................................. ...2222
Alberta College of Art & Design... ...5110
Ambrose University..................... ...9041
Athabasca University.................... ...2204
Bow Valley College...................... ...2218
Concordia University College (AB). .2246
Devry Institute of Technology......... .2040
Grande Prairie Regional College..... .2241
Grant MacEwan University............ .2247
Keyano College............................... .2230
Kings University College................ .2255
Lakeland College............................. .2225
Lethbridge College.......................... .2220
Medicine Hat College......................,2242
Mount Royal University........ ......... 2243
Northern Lakes College......... .........2020
Norquest College................... ......... 2226
Olds College.......................... .........2224
Portage College...................... .........2219
Red Deer College................... .........2244
St. Mary’s ............................... .........5661

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships
Jason Lang
Scholarship

Page
 JASON LANG SCHOLARSHIP
This scholarship was established in memory of Jason Lang, a 17 year old high school student who was killed in a school
shooting. The scholarship recognizes and rewards Alberta post-secodary students for their academic achievements and
encourages them to continue in their undergraduate or professional program of study.

Award Value - $1,000

Eligibility Criteria

To be eligible an applicant must:

• be a Canadian Citizen or Permanent Resident (visa students are not eligible),
• be an Alberta resident and to be considered an Alberta resident one of the following conditions must apply:
- one parent must currently be residing in Alberta, or
- Alberta is the last place you have lived for twelve (12) consecutive months before being a full-time student, or
- you are married to an Alberta resident before the start of your qualifying year of study.
• be enrolled in an undergraduate or professional program such as Law, Medicine, Pharmacy, Dentistry or Veterinary
Medicine at a participating post-secondary educational institution in Alberta,
• be enrolled in a program of study which is a minimum of two years in length or greater, i.e. a program must offer a
minimum of four academic terms or 64 weeks of academic instruction, excluding work term and/or co-op, and
• have completed at least 80% of a full course load and achieved a minimum Grade Point Average of 3.2 on a 4.0 scale
in the previous academic year during the fall and winter semesters.

Students who are nominated for a scholarship and transfer to a non-participating post-secondary institution are eligible to
receive payment of the scholarship. Students must be continuing their post-secondary studies in the 2014-2015 academic year
and must provide confirmation of their full-time enrollment to Alberta Scholarship Programs.

Students are not eligible for a Jason Lang Scholarship if they:

• are enrolled in a one year certificate program,
• interrupt their post-secondary studies for more than one semester in the next academic year,
• are recipients of a Louise McKinney Scholarship for the same period of study, or
• have received the lifetime maximum of three Jason Lang Scholarships.

Selection Procedure
Students who meet the eligibility criteria are nominated by the Student Awards Office at the Alberta post-secondary institution
where they completed their qualifying year of studies.

Payment of the Award

To receive payment of the award, nominees must be:
• continuing their post-secondary studies in the next academic year, either the fall or winter semesters, and
• enrolled full-time, i.e. taking a minimum of a 60% of a full course load for a minimum of one semester.

Students who are nominated in the fall semester receive their cheque in mid-December and students who are nominated
in the winter semester receive their cheque at the end of March.

Submit your completed application form to the Student Awards Office at your
educational institution.

Page 300
 JASON LANG SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number (go to www.education.gov.ab.ca to find your ASN or to obtain one) Social Insurance Number

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal nam e)

Mailing Address (Include Apt, or Box Number) Citv/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender Date of Birth Email Address

day month year

CITIZENSHIP (check one)
□ CANADIAN CITIZEN or □ PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY*
*Do vour parents currently live in Alberta? *Have you lived in Alberta all your life? I f ‘NO’ since_____
_ l___ I J___ I___ L
month year

EDUCATION INFORMATION
Previous Academic Year: 2013-2014 Name of Program------------------------------------------------

Name of Educational Institution_____________________ Academic Year Start Date Academic Year End Date

month year month year

Student ID
Length of Program: | | Years

*If your parents do not currently reside in Alberta AND you have not lived in Alberta all your life, please include
a letter explaining the time spent in Alberta as a non full-time student.

Office Use Only

Revised: April 2014

Page 301
EDUCATION INFORMATION (continued)
Current Academic Year: 2014-2015

Name of Educational Institution Academic Year Start Date Academic Year End Date

month year m onth year

Length of Program I I Years

NB - A student may receive no more than the lifetime maximum of three Jason Lang Scholarships.

Declaration of Applicant
I have read and understand the instructions, and declare that:
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from
full-time studies before completing one semester of studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic record may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may be
released and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Scholarship Programs and for the use in research and
statistical analysis in program evaluation.
I understand and agree that:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships

Page 302
 N O M I N A T I O N F O R

Jimmie Condon
Athletic Scholarship
 Jimmie Condon Athletic Scholarship
The Jimmie Condon Athletic Scholarship was named in honour of Jimmie Condon, philanthropist and long-time supporter and
promoter of amateur sports in Calgary. The scholarship rewards athletic and academic excellence at universities, colleges and
technical institutes in Alberta.

The Jimmie Condon Athletic Scholarship is funded by the Government of Alberta as part of Alberta Enterprise and Advanced
Education Achievement Scholarship Program.

Award Value - Up to $1,800

Eligibility Criteria

To be eligible, a student athlete must be:

• a member of a designated university, college or technical institute team, or
• a member of a Provincial Disabled Athletic Team recognized by the Alberta Athlete Development Program.

In addition, a nominee must:

• be a Canadian Citizen or permanent resident (visa students are not eligible),
• be an Alberta resident as defined by the Jimmie Condon program regulations - a student will be considered an Alberta resident
if a parent or parents currently reside in Alberta, or Alberta is the last place the student has lived for twelve (12) consecutive
months before being a full-time student, or the student was enrolled full-time at a designated post-secondary institution for two
consecutive semesters during a regular academic year, or is married to an Alberta resident before the start of the qualifying year
of study,
• enrolled full-time defined as taking a minimum of a 60% course load or greater in the qualifying semester, and
• maintain a practice and training program acceptable to their coach.

Returning students: must have maintained a GPA (Grade Point Average) of 2.0 on a 4.0 grade point scale on their previous term of
full-time study, (excluding spring and summer courses),
New students who have had a break in their studies do not need to meet the above GPA requirement.

Students in an upgrading or college preparation program may qualify after completing one semester of upgrading providing they
meet the academic and athletic requirements. Apprenticeship students are also eligible for this scholarship.

The scholarship is paid in two installments of $900 each - the first in December and the second in April. Recipients must continue
to meet the eligibility criteria in order to receive the second disbursement.

Members of designated teams are nominated by the Athletics Department at the post-secondary institution they are currently attending.
Contact the Athletics Department for further information.

Nomination Procedure

Return the completed nomination form to the team coach.

For information on this award and other scholarships administered by Alberta Scholarship Programs contact:

Telephone: 780.427.8640
E-mail: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Page 304
 JIMMIE CONDON ATHLETIC SCHOLARSHIP

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under the
Alberta Heritage Scholarship Act and to administer Alberta Scholarship Programs. If you have any questions about the collection of
this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta
T5J 4R4 Phone 780.427.8640.

Personal Information
You m a y use th e L e a r n e r R e g is try a t w w w .e d u c a tio n .g o v .a b .c a to fin d y o u r A lb e rta S tu d e n t N u m b e r o r to h a v e o n e a ssig n e d .

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname:
Province Postal Code Arc t Code Telephone Number

CITIZENSHIP (check one) ALBERTA RESIDENCY (answer both)

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta?
PERMANENT RESIDENT (Landed Immigrant) Y N Have you lived in Alberta for the last 12
N o te : Include a photocopy o f perm anent resident card. consecutive months as a non full-time
Visa students are not eligible.
student before attending school full-time?
Gender (circle one) Birthdate (Day/M onth/Year) OR Have you attended a post-secondary
institution full-time in Alberta for the last
M F ___l___ ___1___ ___l___ l___ l___ two consecutive semesters?
I f y o u h a v e a n s w e r e d ‘ N O ’ t o B O T H q u e s t io n s , p le a s e a t t a c h a le tte
POST-SECONDARY EDUCATION e x p la in in g y o u r t im e s p e n t in A lb e r ta .

Institution currently attending: Name of program:

Name of Sport Student ID Number:

Are you applying as a Provincial disabled athlete? N E-Mail Address:

Office Use Only

27 8 8 8 © 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u r s e m e n t
D ecem ber - 900 E
A p ril - 9 0 0
SPORT MO YR AUTHORIZATION AWARD KEY APP KEY
Revised June 2014

Page 305
 Educational Record

Post-Secondary Education: list the last two post-secondary schools attended to date including current institution.
PERIOD OF STUDY INSTITUTION ENROLLMENT STATUS
F rom (m m /yy) To (m m /yy) N am e o f In stitu tio n P ro g ram Y ear o f P ro g ram L ength of P ro g ram

Declaration of Nominee

1 HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated, and
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
or drop to part-time studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my post-secondary academic record and enrolment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the purpose of determining
my eligibility for a scholarship, and
b. personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship
Programs, and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if 1 receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

To be completed by the Nominating Institution

Name of Nominating Institution

Term: Fall □ Winter □
Name of Coach Signature of Coach (in ink)
 Jo-Anne Koch
Action for Bright Children
(Calgary) Society Awards
 Jo-Anne Koch - ABC Society Awards

Named in honour of Jo-Ann Koch, the first Principal of ABC (Westmount) Charter Public School in Calgry. As a parent of a gifted
child, and a long-time educator in Alberta’s publicly-funded schools, Ms. Koch was a tireless advocate for the rights and needs of
gifted learners..

Award Value - Up to two awards of $500 each

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Permanent Resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have completed Grade 12 requirements at a publicly funded Alberta high school,
c. meet the criteria for Giftedness as determined by his/her school jurisdiction, and,
d. plan to enroll or be enrolled full-time in a post-secondary program.

Application Procedure
Application forms are available from high school counsellors and Alberta Scholarship Programs.

Applicant must:
* complete an application form,
* submit a 150-250 word personal statement outlining how you perceive your Giftedness as you embark on
your post-secondary education journey, and
* include a letter of support from your high school.

Selection Criteria*

A selection committee established by the Action for Bright Children (Calgary) Society will select the recipients. Selection will take
into consideration the following:

* The strength of the school recommendation as determined by the letter of support from the Administration or Counselling
Department, and
* The strenght of the student’s 150-250 word essay.
* Preference will be given to applicants who have received extra support for their learning needs.

To recognize the historic connection between th ABC (Calgary) Society and Westmount Charter School, one recipient will be
selected from Westmount Charter School in Calgary. In the event there is no suitable candidate from Westmount Charter School,
both awards will be offered to qualified students from other Alberta High Schools.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Application Deadline: April 1

 Jo-Anne Koch - ABC Society Awards
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

P re v io u s S u rn a m e
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M F dfy | mopth | , y^ar f

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____ I____ ____ I____ I____ I____
I f y ou h av e a n sw e re d “ N O ” to one o f th e A lb e rta R e sid en c y q u e stio n s , p lea se in c lu d e a le tte r e x p la in in g th e tim e s p e n t in A lb e rta
as a n o n fu ll-tim e stu d e n t.

Name of high school you graduated from: __________________________________________________

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month | year month I year
____ i____ ____ i___ j ____ i____ J ____ I____ I___ J ____ L
Institution City Length of Program Year of Program
y 2nd 3rd

Office Use OnhV

121 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Jisbursement E

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: March 2013

Page 309
 Personal Statement

Include with your application a 150-250 word personal statment outlining

how you perceive Giftedness as you embark on your post-secondary
education journey.

Note: Please include a letter of support from your school.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and
between Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a
scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the purpose of
determining my eligibility for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any
provincial government departments, boards or institutions to verify the information I have provided to Alberta
Scholarship Programs and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however,
this is not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships

Page 310
 Keyera Energy

Peter J. Renton Memorial

Scholarship

^ A ib e rtf^ .
 Keyera Energy
Peter J. Renton Memorial Scholarship
Established in memory of Peter J. Renton who, during a career in the energy sector that spanned 40 years, recognized that
environmental protection, social responsibility and a competent and experienced workforce are essential components of a successful
business. He also believed in life long learning that builds upon education and experience.
The scholarship is intended to assist and encourage Alberta students to pursue full-time studies in a post-secondary program in a field
related to the oil and gas industry.

Award Value
Maximum value is S6,000 - $3,000 for first year of study and $3,000 in the second year providing the recipient remains in good
standing and continues into the second year of their program with a minimum course load of three eourscs per semester.

Eligibility Criteria
Applicants must:
• be a Canadian Citizen or permanent resident,
• be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the qualifying grades,
• have completed the requirements for high school graduation in Alberta, and
• plan to enroll full-time in an accredited Alberta post-secondary institution in the first year of a degree or diploma program in
a field of study supporting the oil and gas industry, including but not limited to: business, communications, sciences and
engineering, technical programs, information technology and the trades.
Note: Family of Keyera Energy employess are eligible to apply.
Relatives of the selection committee members are not eligible.

Selection Procedure

A selection committee established on behalf of Keyera Energy and Alberta Scholarship Programs will select an award recipient based
on a combination of community sendee, employment, athletics, leadership, and/or academic achievement.

Application Procedure*•
Submit a completed application during your last year of high school and include with your application the following:
• References:
*One reference from the School Principal or school representative.
*Two other references, ideally one reference from a teacher, counselor or coach, and one other reference from someone who
is not connected with the school, e.g. employer, mentor, representative from volunteer organization.
• Your answers to the questions in Part 2 of the application., and
• A typed statement in Part 3 of the application on how you would compare your personality and characteristics to those of
Peter J. Renton.

Mail to: Courier or Deliver to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB T5K 2V1

Application Deadline is: May 1

 KEYERA ENERGY
Peter J. Renton Memorial Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor-9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Please review your application to ensure you have completed all the required fields
Missing information may cause delay in processing your application.

Part 1 - Personal Information

Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M
_L J ____ I____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Did you or your parent(s) live in Alberta during your Grade 12 school years?
If no, please include a letter indicating where you or your parent(s) lived during your Grade 12.

PROPOSED POST-SECONDARY STUDIES (Indicate first choice)

m onth year

Revised January 2014

Page 313
 SECONDARY EDUCATION
Name of High School: ------------------------------

Town/City: ---------------------------------------------

Date of Completion of High School (month/year):

Part 2

On a separate sheet, in 150 w ords or less, double spaced, use a f o n t size no sm aller than 10,
p le a se p ro vid e y o u r answ ers to the fo llo w in g questions.

1. What are your plans after high school?

2. What subjects do you enjoy at school and why?

3. What area do you plan to study? How does this area complement the oil and gas industry?

4. What are your favourite activities inside and outside of school?

Are you involved in any organizations,volunteer projects, sports, employment, or hobbies?
List up to 5 areas o f involvement, indicating your level and time o f involvement.

5. What do you consider your best qualities/attributes?

6. What do you consider your best accomplishments?

7. How did you first hear about the Peter J. Renton Memorial Scholarship?

Page 314
 Part 3
Peter J. Renton Memorial Scholarship
Biography

After reading the biography of Peter J. Renton, how do you compare your personality and charactersistics
to his? Please provide examples in a typewritten statement of no more than 300 words.

Candidates should reflect on Peter's example of integrity, humour, leadership and diverse interests when
they complete their application.

People who worked with Peter throughout his 40-year career in the energy sector immediately recall his integrity,
humour, commitment to fair play, and most of all, his resolve to "do the job right." A man of wide interests and
infectious curiosity, he approached every task and every relationship with a passion. Tenacious when he believed in
someone or something, he never let an obstacle deter him from doing what needed to be done. He valued honesty
more than anything and believed that integrity is the cornerstone of both personal and business dealings. A serious
and accomplished professional, he loved to laugh and took great delight at seeing the funny side of things. He
loved time with his family and friends, golf, sports cars and other interests too numerous to mention. In short, he
was an inquisitive, multidimensional man.

Peter's career spanned many aspects of the oil and gas industry. After graduating from Mechanical Engineering at
the University of Calgary, he began his career in Argentina with an oil and gas service company. Returning to
Canada, he joined Gulf Canada Resources where he worked for 25 years in a variety of roles, including oil and gas
production, natural gas processing, and natural gas liquids marketing. This diverse experience was the basis for the
insight and knowledge that Peter happily shared with co-workcrs. In 1998, Peter was a member of the management
group that left Gulf Canada to form Keyera Energy's predecessor company Gulf Midstream Services. Over the next
ten years, he was a key contributor to Keyera's success.

Peter recognized that environmental protection, social responsibility and a competent and experienced workforce arc
essential components of a successful business and, in 2003, he assumed responsibility for these elements at Keyera.
His commitment to "doing the right thing" in all aspects of business led Peter to build protocols and systems that to
this day help Keyera balance diverse stakeholder expectations, respect the environment and promote the health and
safety of employees and the communities in which they work.

Peter believed in life-long learning that builds upon education and experience. Combined with his drive to promote
safe, efficient and reliable operations, this led him to seek ways to engage employees in on-going skills upgrading
and certification. In addition to sharing his experience and vision, he was instrumental in the development of
Keyera's innovative Competency Management and Development System. This important program is now used by
many companies throughout the Canadian oil and gas sector.

As a mentor, Peter was quick to recognize the potential in others. He took great pleasure in asking questions,
sharing his knowledge, and in reinforcing behaviour that leads to success. Many people working in oil and gas
credit Peter with providing them the opportunity to develop their talents and skills and reach their full potential.

Peter's legacy of commitment and actions continues to benefit Keyera today. This scholarship was created to
commemorate this legacy by assisting individuals with similar characteristics to pursue a post secondary education
leading to a career in the oil and gas industry.
 Part 4
Peter J. Renton Memorial Scholarship
References
You must provide three references and these should be sent to Alberta Scholarship Programs:

1. One reference must be from the School Principal or school representative.

2. Two other references ideally one reference from a teacher, counselor or coach, and one other reference from
someone who is not connected with the school, e.g. employer, mentor, representative from volunteer organization.
Please select individuals who know you well so they might comment not only on your academic abilities but also on
your qualities of character, attitudes, and social adaptability. If you have only recently joined your present school,
one of the teacher recommendations may come from your previous school.

Please list the names of your references here:

Name of School Principal or representative:

Name of individual completing a general reference (1):

Name of individual completing a general reference (2):

School Principal

This student has applied for Peter./. Renton Memorial Scholarship. The scholarship was created to commemorate the
legacy of Peter J. Renton by assisting individuals with similar characteristics to pursue post secondary education leading to a
career in the oil and gas industry. Candidates and their principals should reflect on Peter's biography and his example of
integrity, humour, leadership and diverse interests when they complete their applications.

The Scholarship Selection Committee would greatly appreciate your comments on this applicant. If two or more candidates
are applying from one school, the selection committee asks that you provide an indication of the school's first choice

Please comment on both the strengths and weaknesses of the candidate and mail to the address below. Do not return your
comments to the student or his/her parents/guardians.

The deadline for receipt of your reference is May 1. Faxed or scanned references will be accepted.

General Reference

The Scholarship Committee would greatly appreciate your comments on this applicant. Your frank assessment would be
invaluable. All student evaluations arc handled in strict confidence.

Please include a letter commenting on both the strengths and weaknesses of the candidate and send to the address below.
Do not return your comments to the student or his/her parents/guardians.

The deadline for receipt of your reference is May 1. Faxed or scanned references will be accepted.

Mail your reference to:
Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, AB T5J 4R4
Courier or Deliver your reference to: Eax. 780 427 1288
Alberta Scholarship Programs Email: scholarships@gov.ab.ca
4th Floor, 9940 106 Street
Edmonton, AB T5K2V1
Page 316
 Part 5 - Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full­
time studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT:
a. personal information pertaining to my high school academic record may be released and exchanged by
and between Alberta Education and Alberta Scholarship Programs for the purpose of determining my
eligibility for a scholarship;
b. personal information pertaining to my post-secondary academic enrollment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. personal information may be released and exchanged by and between Alberta Scholarship Programs
and any provincial government departments, boards or institutions to verify the information I have
provided to Alberta Scholarship Programs, and for the use in research and statistical analysis in
program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes

University of Alberta....................... 2201
University of Calgary...................... 2202
University of Lethbridge.................. 2203
NAIT................................................ 2221
SAIT................................................ 2222
Alberta College of Art & Design.....5110
Ambrose University College........... 9041
Athabasca University....................... 2204
Banff Centre..................................... 2227
Bow Valley College......................... 2218
Concordia University College (AB)..2246
Devry Institute of Technology.......... 2040
Grande Prairie Regional College...... 2241
Grant MacEwan University.............. 2247
Keyano College................................ 2230
Kings University College................. 2255
Lakeland College.............................. 2225
Lethbridge College........................... 2220
Medicine Hat College...................... 2242
Mount Royal University.................. 2243
Northern Lakes College................... 2020
Norquest College............................. 2226
Olds College.................................... 2224
Portage College................................ 2219
Red Deer College............................. 2244
St. Mary’s University College......... 5661
Taylor University............................. 2268

Inform ation on other aw ards adm inistered by A lberta Scholarship Program s can be
obtained at: alis.alberta.ca./scholarships
 N O M I N A T I O N F O R

Languages in
Teacher Education
Scholarship
 Languages in Teacher Education Scholarship
This program is designed to reward Alberta post-secondary students enrolled in a recognized Alberta teacher preparation
program taking courses that will allow them to teach languages other than English, including FNMI languages in Alberta
schools. This scholarship was created by an endowment from the Government of Alberta to the Alberta Heritage
Scholarship Fund to build provincial capacity in the area of language education.

Teachers interested in summer professional development in the area of another language should contact Alberta
Scholarship Programs regarding the Language Teacher Bursary Program.

Award Amount 2,500

Eligibility Criteria
A nominee must be:

• a Canadian Citizen or Permanent resident - visa students are not eligible;

• an Alberta resident - to be considered an Alberta resident one of the following conditions must apply:
*a parent or parent(s) is currently residing in Alberta, or
*Alberta is the last place the nominee has lived for 12 consecutive months before being a full-time student, or
*is married to an Alberta resident before the start of the qualifying year of study, and
• enrolled full-time in the final two years of a recognized Alberta teacher preparation program offered by an Alberta
Faculty of Education.

Nomination Procedures
Recipients are nominated by the Faculty of Education at each eligible post-secondary institutions. Institutions will select
students who meet the eligibility criteria and who are completing an education program that will allow them to be a
language teacher in Alberta schools after they graduate.

Institutions:
• must balance the nominations across the range of language programs, including FNMI languages, and
• may use academic performance to select recipients.

To help meet the needs of the increasing FNMI (First Nations, Metis, Inuit) student participation, institutions will give
consideration to students eligible to teach aboriginal languages.

Note: A student may only receive this scholarship once.

Eligible Institutions and Allocation of Awards

University of Alberta 4 S c h o la r s h ip s Concordia University College of Alberta 1 S c h o la r s h ip
Campus St. Jean 1 S c h o la r s h ip s Canadian University College (Alberta cohort) 1 S c h o la r s h ip
University of Calgary 3 S c h o la r s h ip s Kings University College 1 S c h o la r s h ip
University of Lethbridge 2 S c h o la r s h ip St. Mary’s University 1 S c h o la r s h ip
Mount Royal University 1 S c h o la r s h ip Ambrose University 1 S c h o la r s h ip

c NOMINATION DEADLINE: NOVEMBER 1 )

Page 319
 LANGUAGES IN TEACHER EDUCATION SCHOLARSHIP
^ We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under
the Alberta Heritage Scholarship Act and to administer Alberta Scholarship Programs. If you have any questions about the
collection of this information, please contact Alberta Scholarship Programs, 4th Floor-9940 106 Street, Edmonton, Alberta
T5J 4R4 Phone 780.427.8640.
V J

Personal Information

r Alberta Student Number (go to w w w .e d u c a tio n .g o v .a b .c a to find your ASN orto obtain one) Social Insurance Number " \

Mailing Address (Include Apt. or Box Number) City/Town

Province Postal Code Area Code and Telephone Number E-Mail Address

CITIZENSHIP (check one) r ALBERTA RESIDENCY answ er both) " A

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta?

PERMANENT RESIDENT (Landed Immigrant)
N o te : Attach a photocopy o f perm anent resident card or Y N Have you lived in Alberta for the last 12
im m igration long form. Visa students are not eligible consecutive months as a non full-time student?
OR Are you currently married to an Alberta
Gender (circle one) Birthdate (Day/M onth/Year) resident?
IF Y O U H A V E A N S W E R E D ‘N O ’ T O B O T H Q U E S T IO N S ,
M F
___I___ ___I___ _ l ____I___I___ P L E A S E A T T A C H A L E T T E R E X P L A IN IN G Y O U R R E S ID E N C Y ,

POST-SECONDARY EDUCATION
2013-2014 2014-2015
Name of post-secondary institution: Name of-post-secondary institution:

Name of program: Name of program:

Year of Program Year of Graduation

Indicate your grade level of focus:
Elementary Education: _____ □ of □
Secondary Education: _____
^Jpon completion of your program, do you plan to teach in Alberta? |y IN

Office Use Only

50 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
Disbursement

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: April 2014

Page 320
 Language Background
F o r F N M I n o m in e e s , w h a t le a r n in g /b a c k g r o u n d w ill a llo w y o u to te a c h y o u r
W h a t is y o u r First la n g u a g e /m o th e r to n g u e ? la n g u a g e a n d c u ltu re (e .g . a t u n iv e r s ity , c o lle g e , C IL L D I, A T E P ).

I n d ic a te th e la n g u a g e ( s ) y o u w ill b e a b le to te a c h u p o n c o m p le tio n o f y o u r A lb e r ta te a c h e r p r e p a r a tio n p ro g r a m :

In d ic a te w h e r e y o u p la n to te a c h th e a b o v e la n g u a g e (s ) a n d w h y y o u w a n t to te a c h la n g u a g e s :

Declaration of Nominee

r I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. a ll in f o rm a tio n p r o v id e d is tru e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
" \

b. I a m a fu ll-tim e s tu d e n t in th e la s t tw o y e a rs o f a n A lb e r ta te a c h e r p r e p a r a tio n p r o g r a m a t th e in s titu tio n n a m e d fo r th e

p e r io d s ta te d ,
c. I in te n d to te a c h th e la n g u a g e ( s ) a b o v e in A lb e r ta u p o n c o m p le tio n o f m y E d u c a tio n p r o g r a m , a n d
d. I w ill im m e d ia te ly n o tify th e o ff ic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r itin g i f I w ith d r a w fro m f u ll-tim e s tu d ie s
o r d ro p to p a r t- tim e s tu d ie s .

I UNDERSTAND AND AGREE THAT:

a. m y p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic re c o r d a n d e n r o llm e n t s ta tu s m a y b e r e le a s e d a n d
e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g
m y e lig ib ility fo r a s c h o la rs h ip ,
b. m y p e rs o n a l in f o rm a tio n m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y p r o v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e rify th e in f o rm a tio n I h a v e p r o v id e d to A lb e rta S c h o la r s h ip P ro g r a m s ,
a n d f o r th e u s e in re s e a rc h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

UNDERSTAND AND AGREE THAT:

i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a rd a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is n o t a
c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g ra m s .

V S ig n a tu r e o f A p p lic a n t (in in k ) T o d a y ’s D a te (in in k )

J
To Be Completed by the Nominating Institution

T h is is c o n f ir m th a t th e a b o v e n a m e d s tu d e n t h a s b e e n n o m in a te d b y th is in s titu tio n to re c e iv e a
L a n g u a g e s in T e a c h e r E d u c a tio n S c h o la r s h ip .
N a m e o f N o m in a tin g In s titu tio n D a te

N a m e o f U n iv e r s ity O ffic ia l S ig n a tu re o f U n iv e r s ity O ffic ia l (in in k )

S tu d e n ts s tu d y in g in F re n c h m a y a ls o b e e lig ib le f o r th e Fellowship fo r Full-time Studies in French. In f o r m a tio n is a v a ila b le fr o m

A lb e r ta S c h o la r s h ip P r o g r a m s W e b s ite a t alis.alberta.ca/scholarships
Page 321
Language Bursary
Program
for Teaching FNMI
Languages
 Language Bursary Program for Teaching FNMI Languages
T h e L a n g u a g e T e a e h c r B u rs a r y p r o g r a m w a s c re a te d b y a n e n d o w m e n t to th e A lb e rta H e rita g e S c h o la r s h ip F u n d a s p a r t o f th e
g o v e r n m e n t o f A lb e r t a ’s E c o n o m ic D e v e lo p m e n t S tra te g y . It w a s e s ta b lis h e d so te a c h e r s m a y im p ro v e th e ir la n g u a g e flu e n c y ,
p e d a g o g ic a l s k ills a n d k n o w le d g e th r o u g h a n e d u c a tio n a l im m e r s io n e x p e rie n c e , a n d to h e lp A lb e rta j u r is d i c ti o n s e n h a n c e th e ir
c u r r e n t la n g u a g e te a c h in g c a p a c ity .

U p to tw o b u rs a rie s o f $ 2 ,5 0 0 fo r s tu d y in C a n a d a .

T h e p ro g r a m w ill a s s is t A lb e rta te a c h e r s , E ld e rs o r in s tru c to rs c u r r e n tly p r o v id in g in s tru c tio n o f a n F N M I la n g u a g e a n d in te n d to ta k e

a s u m m e r p o s t - s e c o n d a r y p ro g r a m . S tu d e n ts w ill b e n e fit fro m th e e n h a n c e d te a c h in g a n d la n g u a g e s k ills o f th e ir te a c h e rs ,
e n c o u r a g in g th e m to ta k e u p th e c h a lle n g e o f le a r n in g a n F N M I la n g u a g e a n d c u ltu re a n d to a s s is t w ith th e F N M I la n g u a g e
re v ita liz a tio n a n d /o r re n e w a l.

P o s t-s e c o n d a r y s tu d e n ts in a re c o g n iz e d te a c h e r p r e p a r a tio n p r o g r a m in A lb e rta s h o u ld c o n ta c t A lb e rta S c h o la r s h ip P ro g r a m s a b o u t

th e L a n g u a g e s in T e a c h e r E d u c a tio n S c h o la r s h ip .

Eligibility Criteria
A p p lic a n t m u s t:
• b e a C a n a d ia n C itiz e n o r P e rm a n e n t R e s id e n t, a n d b e a n A lb e rta r e s id e n t,
• e ith e r b e w o rk in g to w a rd s A lb e r ta c e r tif ic a tio n o r h o ld a v a lid A lb e rta p r o f e s s io n a l te a c h in g c e r tif ic a te ;
• h a v e b e e n te a c h in g in A lb e r ta fo r a m in im u m o f o n e y e a r b y th e e n d o f th e c u r r e n t s c h o o l y e a r;
• d e m o n s tr a te a b a c k g r o u n d in F N M I la n g u a g e le a r n in g a n d c u ltu re , o r h a v e re c e n tly in itia te d th e s tu d y o f a n F N M I la n g u a g e ;
• p la n to ta k e a s u m m e r p r o g r a m o f a t le a s t th r e e w e e k s d u r a tio n in a n in d ig e n o u s la n g u a g e te a c h in g m e th o d o lo g y .
Note: P rio rity w ill b e g iv e n to firs t tim e a p p lic a n ts , h o w e v e r, p r e v io u s r e c ip ie n ts o f th r e e o r m o r e y e a r s a g o m a y a p p ly .

Program Eligibility Criteria

T h e s u m m e r la n g u a g e d e v e lo p m e n t p r o g r a m m u s t b e :
• a u n iv e r s ity c re d it c o u r s e f o c u s in g o n la n g u a g e , c u ltu r e a n d /o r p e d a g o g ic a l d e v e lo p m e n t, e .g . C IL L D I
• a minimum o f th r e e w e e k s in d u ra tio n , a n d
• a minimum o f th r e e h o u rs d a ily s c h e d u le d c la s s r o o m in s tru c tio n , w ith a n e x p e c ta tio n o f a d d itio n a l s c h e d u le d , s tr u c tu r e d
a c tiv itie s (e .g . la n g u a g e c o n v e r s a tio n , tu to r ia ls , c u ltu r a l a c tiv itie s ).

Selection Procedure
B u rs a r y re c ip ie n ts w ill b e c h o s e n b y a s e le c tio n c o m m itte e w ith d e c is io n s b a s e d o n th e a p p lic a n t's s ta te m e n t o f p r o g r a m , s c h o o l, a n d
s c h o o l a u th o r ity e n d o rs e m e n t. T h e s e le c tio n c o m m itte e b a s e s its d e c is io n s o n in f o r m a tio n s u b m itte d w ith th e a p p lic a tio n a n d a n y
c h a n g e s m a y j e o p a r d iz e th e re c e ip t o f p a y m e n t o f th e b u rs a ry .

Application Procedure
In c lu d e w ith y o u r a p p lic a tio n a c o p y o f y o u r re s u m e . S u b m it th e c o m p le te d a p p lic a tio n p a c k a g e (a p p lic a tio n fo r m a n d s u p p o r tin g
d o c u m e n ts ) to y o u r sc h o o l ju r is d i c ti o n (s u p e r in te n d e n t o r d e s ig n a te ) , o r F irs t N a tio n s E d u c a tio n A u th o rity f o r e n d o rs e m e n t. O n c e
e n d o r s e m e n t h a s b e e n g iv e n , th e s c h o o l j u r is d i c ti o n o r th e F irs t N a tio n s E d u c a tio n A u th o rity w ill fo r w a rd y o u r a p p lic a tio n to A lb e rta
S c h o la r s h ip P ro g r a m s fo r c o n s id e ra tio n .

A p p lic a n ts a re r e m in d e d to m e e t th e i r s c h o o l ju r is d i c ti o n p r o c e d u r e s a n d d e a d lin e s . T h e s c h o o l a u th o r ity m u s t m a il its e n d o rs e m e n t,

a lo n g w ith th e a p p lic a tio n p a c k a g e to A lb e rta S c h o la r s h ip P ro g r a m s b y February 10.

Submit your completed application to your school jurisdiction (superintendent or designate) or

First Nations Education Authority for endorsement. The school authority will then submit your
application to Alberta Scholarship Programs by February 10.
 Language Bursary Program for Teaching FNMI Languages

W c a rc c o lle c tin g th e p e rs o n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F re e d o m o f In fo rm a tio n a n d P ro te c tio n

o f P riv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e s s a ry to d e te rm in e y o u r e lig ib ility fo r a n a w a rd u n d e r th e A lb e rta H e rita g e
S c h o la rs h ip A c t a n d to a d m in is te r A lb e rta S c h o la rs h ip P ro g ra m s. I f y o u h a v e a n y q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n , p le a s e
c o n ta c t A lb e rta S c h o la rs h ip P ro g ra m s , 4 th F lo o r-9 9 4 0 106 S tre e t, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information
AB Professional Teaching C e rt. N o. (if a p plicable) * A lberta S tudent N u m b e r (ASN) S o cial In s u ra n c e N u m b e r

L a s t N a m e (fu ll le g a l n a m e ) F ir s t N a m e a n d O n e In itia l (fu ll le g a l n a m e )

M a ilin g A d d r e s s (include Api. or Box Number) C ity /T o w n

* Y o u m a y u s e th e L e a rn e r R e g is try a t
www.education.gov.ab.ca to fin d y o u r ASN
o r to h a v e o n e a s s ig n e d .
P ro v in c e P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

CITIZENSHIP ( c h e c k one) Number of Years of Teaching or Instructing in Alberta:

CANADIAN CITIZEN OR Full-time ______ Part-time______

PERMANENT RESIDENT

NOTE
Recipients will receive their bursary after submitting proof of completing their course.
S c h o la r s h ip s , fe llo w s h ip s a n d b u r s a r ie s a re ta x e x e m p t, h o w e v e r, p le a s e c o n ta c t th e C a n a d a R e v e n u e A g e n c y fo r d e ta ils o n th e
r e p o r tin g re q u ir e m e n ts a n d ta x tr e a tm e n t o f in c o m e fro m th e s e s o u rc e s .

Office Use Only

Revised: September 2014

Page 324
 Proposed Studies

P ro g r a m N a m e L a n g u a g e o f S tu d y

C o m m e n c e m e n t D a te (Day/M onth/Ycar) C o m p le tio n D a te (Day/M onth/Year)

Proposed Studies:
i 1 i 1 i i i i 1 i 1 i i i No. of Days per week___ No of Weeks____
N a m e o f in s titu tio n o f f e r in g p ro g r a m
No. of Hours of instruction per day: ___
Focus of Studies:
Improving language fluency:
A d d r e s s o f in s titu tio n o ff e rin g p r o g r a m
___ Oral ___ Written
Gaining cultural knowledge___
Enhancing pedagogy ___
Working towards completion of teacher certification.

E la b o ra te o n th e fo c u s o f th e c o u rs e , f o r e x a m p le h o w th is c o u rs e w ill d e v e lo p o r e n h a n c e y o u r k n o w le d g e o f y o u r la n g u a g e
a n d c u ltu r e a n d /o r y o u r te a c h in g s k ills:

Estimated Expenses

H a v e y o u a p p lie d o r w ill y o u b e a p p ly in g f o r fu n d in g fr o m a n o th e r s o u r c e , e .g . F ir s t N a tio n s E d u c a tio n A u th o rity

( F N E A ), to p a r tic ip a te in th is p r o g r a m ?

Y E S ________N O _________

I f “ Y E S ” , p le a s e in d ic a te th e s o u r c e o f f u n d in g a n d a m o u n t o f s u p p o rt::

D o y o u a n tic ip a te r e c e iv in g fu n d in g fr o m a n o th e r s o u r c e , e .g . F N E A , to p a r tic ip a te in th is p r o g r a m ?

Y E S ________ N O _______

I f “ Y E S ” p le a s e in d ic a te th e s o u r c e a n d a m o u n t o f s u p p o rt:
 Please attach a resume including your education and work history.

Language Teaching/lnstructional Experience:

P le a s e p r o v id e a s u m m a ry o f F N M I la n g u a g e s a n d g r a d e le v e l y o u h a v e ta u g h t, o r c u r r e n t ro le in F N M I la n g u a g e s a t y o u r sc h o o l:

□ A la n g u a g e a n d c u ltu re e x p e r t Q A flu e n t s p e a k e r Q N e w to le a r n in g th is la n g u a g e
□ N e w to la n g u a g e te a c h in g r—1 R e tu rn in g to te a c h a la n g u a g e a f te r s o m e tim e
□ E ld e r I n d ic a te y o u r a s s ig n m e n t in th e n e x t s c h o o l y e a r:
□ C u r r e n tly te a c h in g th is la n g u a g e

Language Background: W h a t is th e la n g u a g e y o u a re m o s t p r o f ic ie n t i n ? _____________________________

In d ic a te p r o f ic ie n c y in F N M I la n g u a g e : E x c e lle n t, G o o d , F air, N e e d s im p r o v e m e n t
R e a d in g :
W ritin g :
S p e a k in g :
C u ltu r a l K n o w le d g e :

Supporting Documents*•
Statement of Intent:
A tta c h a s ta te m e n t (o n e p a g e m a x im u m ) e x p la in in g y o u r r e a s o n s fo r ta k in g th e p ro g r a m .
1. H o w w ill th is p a r tic u la r p ro g ra m :
• b e n e fit y o u r c u r r e n t/f u tu r e e m p lo y m e n t a s a n F N M I la n g u a g e te a c h e r in A lb e rta ?
• fit in to y o u r p ro f e s s io n a l d e v e lo p m e n t/g r o w th p la n ?
2. H o w w ill th is b u r s a r y im p a c t y o u r ro le in th e F N M I la n g u a g e s p r o g r a m ?
3. H o w d o y o u p la n to s h a r e th is k n o w le d g e w ith c o lle a g u e s ?

Professional Development Summary:

A tta c h a b r i e f s u m m a ry o u tlin in g re le v a n t p ro f e s s io n a l d e v e lo p m e n t. E n s u re to o u tlin e y o u r r e c e n t e ff o rts to e n h a n c e
a n d /o r d e v e lo p :
1. L a n g u a g e a n d c u ltu re
2. T e a c h in g a n d /o r le a d e rs h ip s k ills in th e a re a o f la n g u a g e te a c h in g

Course Syllabus:.
A tta c h b ro c h u r e o r s y lla b u s d e s c r ib in g th e fo c u s o f th e c o u rs e , its d u ra tio n a n d in te n s ity .

Page 326
 Declaration of Applicant

I HAVE READ THE INSTRUCTIONS, AND DECLARE THAT:

(a ) I h a v e a n s w e r e d a ll q u e s tio n s a p p lic a b le to m e a n d th a t all in f o rm a tio n is tr u e a n d c o m p le te ;

(b ) I p r o p o s e to ta k e th e c o u r s e n a m e d fo r th e p e r io d s ta te d ;
(c ) I w ill n o tify A lb e rta S c h o la r s h ip P r o g r a m s s h o u ld I w ith d r a w fro m s tu d ie s ;
(d ) I a g r e e to a llo w m y n a m e , c ity /to w n , p r o g r a m in f o r m a tio n , s c h o o l, a n d ju r is d i c ti o n to b e r e le a s e d to th e
m e d ia a n d a p p r o p r ia te M e m b e r s o f th e L e g is la tiv e A s s e m b ly (M L A s ) i f I re c e iv e th is a w a rd ; a n d ,
(e ) I a u th o r iz e th e r e le a s e a n d e x c h a n g e o f p e rs o n a l in f o rm a tio n b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d
A lb e rta E d u c a tio n a n d a n y fe d e ra l a n d p r o v in c ia l g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e rify th e
in f o rm a tio n I h a v e p r o v id e d to A lb e rta S c h o la r s h ip P r o g r a m s a n d fo r th e u s e in re s e a rc h a n d s ta tis tic a la n a ly s is in
p ro g r a m e v a lu a tio n a n d p r o g r a m p ro m o tio n .

Signature of Applicant (in ink) Today’s Date (in ink)

Applicant Checklist

A p p lic a tio n is c o m p le te d in its e n tir e ty a n d th e following documents are attached:

□ S ta te m e n t o f In te n t
□ P ro g ra m B ro c h u re o r S y lla b u s
□ P ro f e s s io n a l D e v e lo p m e n t S u m m a ry
□ R esum e
U A p p lic a tio n is s ig n e d , d a te d a n d c o m p le te d in in k .

E n tire a p p lic a tio n p a c k a g e in c lu d in g y o u r c u r r e n t s u p e r v is in g a d m i n is tr a t o r ’s e n d o r s e m e n t (S c h o o l P rin c ip a l

P a rt 1) is fo r w a rd e d to y o u r lo c a l s c h o o l ju r is d i c ti o n o r F irs t N a tio n s E d u c a tio n A u th o r ity fo r re v ie w .

Notes to Applicant

Submit your completed application package to your school jurisdiction or First Nations of Education Authority.
Please allow sufficient time to the local school authority to complete their endorsement in order to meet the
February 10 application deadline.

DO NOT SUBMIT YOUR APPLICATION TO ALBERTA SCHOLARSHIP PROGRAMS

INCOMPLETE APPLICATION WILL NOT BE CONSIDERED

Page 327
 School Endorsement - Part 1
To be Completed by Applicant’s Current School Principal
N o te : T he S e le c tio n C o m m ittee n e e d s clea r a n d co n c ise in fo rm a tio n o n y o u r F N M I la n g u a g e p ro g ra m n e e d s a t y o u r sc h o o l a n d h o w it is
e x p e c te d th e a p p lic a n t’s su m m e r p ro g ra m w ill b e n e fit th e sc h o o l a n d m e e t th e s c h o o l’s F N M I la n g u a g e needs.

NAME OF APPLICANT: ____________________________________________________

W h a t is th e a n tic ip a te d a s s ig n m e n t o f th is a p p lic a n t in th e 2 0 1 5 /2 0 1 6 s c h o o l y e a r? (c o u r s e s , g ra d e , e tc .)

W ill th is a p p lic a n t b e ( c h e c k a ll a p p r o p r ia te b o x e s ):
_____ r e t u r n in g to th e s a m e s c h o o l?
_____ a t a n o th e r s c h o o l? _________________________
_____ ta k in g o n a n e w a s s ig n m e n t?
_____ re tu r n in g to th e s a m e a s s ig n m e n t?
_____ u n s u r e a t th is tim e
_____ o th e r _________________________________________

H o w lo n g h a s th is a p p lic a n t b e e n u n d e r y o u r s u p e r v is io n ? ______________________________________

W h a t la n g u a g e p r o g r a m s /p r o je c ts /in itia tiv e s h a s th is a p p lic a n t le d o r a s s is te d w ith w h ile u n d e r y o u r s u p e r v is io n ?

This school needs FNMI ( c h e c k th e m o s t a p p ro p r ia te ): This applicant is (c h e c k e o n e ):

_____ a le a d /m a s te r te a c h e r in F N M I la n g u a g e & c u ltu re
_____ th is te a c h e r to r e f r e s h /e n h a n c e s k ills
_____ th is in s tr u c to r to o b ta in te a c h in g c r e d e n tia ls
_____ a le a d /m a s te r te a c h e r in th e c h o s e n la n g u a g e
_____ a te a c h e r re tu r n in g to te a c h in g la n g u a g e s
______ n e w to te a c h in g th is la n g u a g e
_____ a n E ld e r c o m m u n ity m e m b e r w h o w is h e s to c o m p le te a
te a c h e r p r e p a tio n p ro g r a m
_____ n e w to la n g u a g e le a r n in g

H o w w ill s tu d e n ts in y o u r s c h o o l b e n e f it fro m th e a p p li c a n t’s e x p e rie n e e ?

H o w w ill th is s u m m e r la n g u a g e p r o g r a m fit in to th is t e a c h e r ’s p r o f e s s io n a l d e v e lo p m e n t?

H o w w ill th is a p p li c a n t’s p a r tic ip a tio n fit in to y o u r s c h o o l ’s F N M la n g u a g e p la n ?

N a m e o f P rin c ip a l ( p le a s e p r in t) S ig n a tu re (in in k ) T o d a y ’s D a te

N a m e o f S c h o o l: S c h o o l L o c a tio n :

S c h o o l A u th o r ity C o n ta c t: P h o n e N u m b e r:

Application Deadline: February 10

 School Authority Endorsement - Part 2
To be Completed by the School Jurisdiction (Superintendent or designate) or First Nations
Education Authority
N o te: T h e S e le c tio n C o m m ittee n e e d s clear a n d co n c ise in fo rm a tio n on y o u F N M I la n g u a g e p ro g ra m n eed s in y o u r sc h o o l division a n d h o w it is
e x p e c te d th e a p p lic a n t’s su m m e r p ro g ra m w ill b e n e fit th e sc h o o l a n d m e e t th e sc h o o l d iv is io n ’s F N M I la n g u a g e needs.

NAME OF APPLICANT: ___________________________________________

T h is a p p li c a n t’s p a r tic ip a tio n in th e d e s c r ib e d la n g u a g e p r o g r a m w ill s u p p o r t th e s c h o o l a u th o r it y ’s la n g u a g e p la n b y (c h e c k

a p p r o p r ia te s ta te m e n t! s):
_____ e n h a n c in g th e la n g u a g e e x p e r tis e a lr e a d y a v a ila b le in th e d is tric t
_____ b e g in n in g to d e v e lo p d is tr ic t e x p e r tis e in th is la n g u a g e
_____ p r o v id in g m u c h n e e d e d le a d e rs h ip to th is s c h o o l
_____ m e e tin g a s ta ffin g n e e d th r o u g h in - s e rv ic e d e v e lo p m e n t o f th is t e a c h e r ’s la n g u a g e s k ills
_____ b e g in n in g th e j o u r n e y o f d e v e lo p in g la n g u a g e p r o g r a m m in g

H o w w ill th e e x p e r ie n c e a n d s k ills a c q u ir e d b y th is a p p lic a n t p a r tic ip a tin g in th is p a r tic u la r p r o g r a m b e n e f it th e s c h o o l a n d s c h o o l

a u th o r ity ?

It is im p o rta n t f o r th e s e le c tio n c o m m itte e to k n o w a b o u t:

- th is a p p lic a n t
- th e la n g u a g e s t a f f n e e d s o f th is s c h o o l
- o th e r k e y c o n s id e ra tio n
- e x p e c te d a s s ig n m e n t in th e n e x t s c h o o l y e a r

N a m e ( p le a s e p rin t) S ig n a tu re (in in k ) T o d a y ’s D a te

P o s itio n S c h o o l A u th o r ity N a m e Phone N um ber

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

A lb e rta S c h o la r s h ip P ro g r a m s A lb e rta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e rta T 5 J 4 R 4 E d m o n to n , A lb e rta T 5 K 2V 1

Telephone: 780.427.8640
Email: s c h o la rs h ip s @ g o v .a b .c a
Website: w w w .a lis .a lb e r ta .a b .c a /s c h o la r s h ip s

Application Deadline: February 10

Language Teacher
Bursary Program
 Language Teacher Bursary Program
T h e L a n g u a g e T e a c h e r B u rs a r y p r o g r a m w a s c re a te d b y a n e n d o w m e n t to th e A lb e r ta H e rita g e S c h o la r s h ip F u n d a s p a r t o f th e
G o v e r n m e n t o f A lb e r t a ’s E c o n o m ic D e v e lo p m e n t S tra te g y . It w a s e s ta b lis h e d so te a c h e r s m a y im p ro v e th e ir la n g u a g e flu e n c y ,
p e d a g o g ic a l s k ills a n d k n o w le d g e th r o u g h a n e d u c a tio n a l im m e r s io n e x p e r ie n c e , a n d to h e lp A lb e r ta j u r is d i c ti o n s e n h a n c e th e ir
c u rr e n t la n g u a g e te a c h in g c a p a c ity .

A p p r o x im a te ly te n b u r s a r ie s o f $ 5 ,0 0 0 e a c h f o r s tu d y o u ts id e o f C a n a d a .

T h e p r o g r a m w ill a s s is t c e rtif ic a te d A lb e rta te a c h e r s to ta k e a s u m m e r p o s t - s e c o n d a r y p r o g r a m in a la n g u a g e o th e r th a n

E n g lis h o r la n g u a g e p e d a g o g y c o u rs e a t a n in s titu tio n o u ts id e o f C a n a d a . T e a c h e rs o f A b o r ig in a l la n g u a g e s , w h o s e la n g u a g e o f
s tu d y is only a v a ila b le in C a n a d a , a re e lig ib le . S tu d e n ts w ill b e n e f it fr o m th e e n h a n c e d p e d a g o g ic a l a n d la n g u a g e s k ills o f th e ir
te a c h e r s , e n c o u r a g in g th e m to ta k e u p th e c h a lle n g e o f le a r n in g a n e w la n g u a g e m a k in g th e m m o re g lo b a lly c o m p e titiv e .

P o s t- s e c o n d a r y s tu d e n ts in a r e c o g n iz e d te a c h e r p r e p a r a tio n p r o g r a m in A lb e rta s h o u ld c o n ta c t A lb e r ta S c h o la r s h ip P ro g r a m s
a b o u t th e L a n g u a g e s in T e a c h e r E d u c a tio n S c h o la r s h ip .

Teacher Eligibility Criteria

A p p lic a n t m u s t:
• b e a C a n a d ia n C itiz e n o r a P e rm a n e n t R e s id e n t, a n d b e a n A lb e r ta re s id e n t,
• h o ld a v a lid A lb e r ta p ro f e s s io n a l te a c h in g c e r tif ic a te ,
• h a v e b e e n te a c h in g in A lb e r ta fo r a m in im u m o f th r e e y e a r s ( F T E ) b y th e e n d o f th e c u r r e n t s c h o o l y e a r,
• d e m o n s tr a te a b a c k g r o u n d in la n g u a g e le a r n in g , o r h a v e re c e n tly in itia te d th e s tu d y o f th is la n g u a g e , a n d
• p la n to ta k e a s u m m e r p r o g r a m o f a t le a s t f o u r w e e k s d u ra tio n in a la n g u a g e a n d /o r la n g u a g e te a c h in g m e th o d o lo g y o th e r
th a n E n g lis h o u ts id e o f C a n a d a .
Note: P rio rity w ill b e g iv e n to firs t tim e a p p lic a n ts , h o w e v e r, re c ip ie n ts w h o r e c e iv e d a b u r s a r y fiv e y e a rs a g o o r e a r lie r c a n
re a p p ly .

Program Eligibility Criteria

T h e s u m m e r la n g u a g e d e v e lo p m e n t p r o g r a m m u s t b e:
• a minimum o f fo u r w e e k s in d u ra tio n ;
• a minimum o f th r e e h o u rs d a ily s c h e d u le d c la s s r o o m in s tru c tio n , w ith a n e x p e c ta tio n o f a d d itio n a l s c h e d u le d , s tr u c tu r e d
a c tiv itie s (e .g . la n g u a g e c o n v e rs a tio n , tu to r ia ls , c u ltu ra l a c tiv itie s );
• a u n iv e r s ity c re d it c o u rs e , o r a la n g u a g e /c u ltu r e /p e d a g o g ic a l d e v e lo p m e n t p r o g r a m , in a la n g u a g e o th e r th a n E n g lis h th a t
is o ff e re d b y a p o s t - s e c o n d a r y in s titu tio n , o r a n o rg a n iz a tio n re c o g n iz e d b y th e lo c a l g o v e r n m e n t (e .g . G o e th e In s titu te ,
C e r v a n te s In s titu te ) o u ts id e o f C a n a d a .

Selection Procedure
R e c ip ie n ts w ill b e c h o s e n b y a s e le c tio n c o m m itte e w ith d e c is io n s b a s e d o n th e a p p lic a n t's s ta te m e n t o f p r o g r a m , c o u r s e rig o u r,
s c h o o l a u th o r ity e n d o rs e m e n t, a n d th e p o te n tia l b e n e fit fo r b o th th e te a c h e r a n d th e s c h o o l a u th o rity . T h e s e le c tio n c o m m itte e
b a s e s its d e c is io n s o n in f o r m a tio n s u b m itte d w ith th e a p p lic a tio n a n d a n y c h a n g e s m a y je o p a r d iz e th e re c e ip t o f p a y m e n t o f th e
b u rs a ry . E v e ry e ff o rt w ill b e m a d e to re p r e s e n t v a rio u s g r a d e le v e ls a n d la n g u a g e s fro m a c ro s s A lb e rta .

Application Procedure
In c lu d e w ith y o u r a p p lic a tio n a c o p y o f y o u r re s u m e . S u b m it th e c o m p le te d a p p lic a tio n p a c k a g e ( a p p lic a tio n fo r m a n d
s u p p o r tin g d o c u m e n ts ) to y o u r s c h o o l a u th o r ity o ff ic e f o r e n d o rs e m e n t. O n c e e n d o r s e m e n t h a s b e e n g iv e n , th e s c h o o l a u th o r ity
w ill fo r w a rd y o u r a p p lic a tio n to A lb e rta S c h o la r s h ip P r o g r a m s fo r c o n s id e ra tio n . S c h o o l A u th o r itie s m u s t m a il a p p lic a tio n s to
A lb e r ta S c h o la r s h ip P r o g r a m s b y F e b r u a i y 10. C o n s e q u e n tly , submit your application to the School Authority' well in
advance to give School Authorities sufficient time to m e e t th e F e b ru a r y 10 s u b m is s io n d e a d lin e .

Submit your completed application to your School Authority.

School Authorities must submit the applications to Alberta Scholarship Programs by February 10.

Page 331
 LANGUAGE TEACHER BURSARY PROGRAM
W c a rc c o lle c tin g th e p e rs o n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F re e d o m o f I n fo rm a tio n a n d P ro te c tio n
o f P riv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e s s a ry to d e te rm in e y o u r e lig ib ility fo r a n a w a rd u n d e r th e A lb e rta H e rita g e
S c h o la rs h ip A c t a n d to a d m in is te r A lb e rta S c h o la rs h ip P ro g ra m s. I f y o u h a v e a n y q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n , p le a s e
c o n ta c t A lb e rta S c h o la rs h ip P ro g ra m s , 4 lh F lo o r, 9 9 4 0 106 S tre e t, E d m o n to n , A lb e rta , T 5 K 2 V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information
A lb erta Professional Teaching C ertificate N u m b e r *A lb erta S tu d en t N u m b e r (ASN) S ocial In s u ra n c e N u m b e r

L a s t N a m e (fu ll le g a l n a m e ) F ir s t N a m e a n d O n e In itia l (fu ll le g a l n a m e )

C ity /T o w n

* Y o u m a y u s e th e L e a r n e r R e g is try a t
www.education.gov.ab.ca to f in d y o u r A S N
P ro v in c e P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r o r to h a v e o n e a s s ig n e d .

CITIZENSHIP ( c h e c k o n e ) NUMBER OF YEARS TEACHING

CANADIAN CITIZEN OR In Alberta** Full-time _______ Part-time______

PERMANENT RESIDENT Outside Alberta Full-time ______ Part-time_______

Location:
G e n d e r (circle one) B irth d a te (Day, M onth, Year)
M F **Minimum of three years (FTE) of teaching in Alberta is required.
I
___I___ ___ I___ ___ I___ I___ I___

E m a il a d d re s s :

N a m e o f u n iv e r s ity y o u r e c e iv e d y o u r te a c h in g d e g re e : Y e a r o f c o m p le tio n :

NOTE
Recipients will receive their bursary after submitting proof of completing their course.
S c h o la r s h ip s , f e llo w s h ip s a n d b u r s a r ie s a re u s u a lly ta x e x e m p t, h o w e v e r, p le a s e c o n ta c t th e C a n a d a R e v e n u e A g e n c y fo r d e ta ils o n
th e re p o r tin g r e q u ir e m e n ts a n d ta x tr e a tm e n t o f in c o m e fro m th e s e s o u rc e s .

Office Use Only

Revised: September 2014

Page 332
 Proposed Studies

NOTE: Receipt of a bursary does not imply recognition of the course by Teacher Qualifications Service

P ro g ra m N a m e L a n g u a g e o f S tu d y

C o m m e n c e m e n t D a te (Day/Month/Year) C o m p le tio n D a te (Day/Month/Year) C o u n tr y

J ___ L
N a m e o f in s titu tio n o f f e rin g p r o g r a m

Proposed Studies:
A d d r e s s o f in s titu tio n o f f e rin g p ro g r a m No. of Days per week___ No of Weeks
No. of Hours of instruction per day: ___
Focus of Studies:
Improving language fluency:
___ Oral ___ Written
Gaining cultural knowledge___
Program/Course Syllabus: Enhancing pedagogy ___

In a m a x im u m o f o n e p a g e , p le a s e d e s c r ib e th e fo c u s o f th e c o u rs e , s p e c ify h o w it
w ill d e v e lo p y o u r la n g u a g e a n d /o r p e g a d o g ic a l s k ills a n d e n h a n c e y o u r k n o w le d g e o f th e c u ltu re . W h y d id y o u c h o o s e th is
p a r tic u la r s c h o o l a n d th is p a r tic u la r c o u rs e ? A tta c h a c o p y o f th e c o u r s e s y lla b u s in E n g lis h .

Statement of Intent:
In a m a x iu m u m o f o n e p a g e , a tta c h a s ta te m e n t e x p la in in g h o w th is p a r tic u la r c o u r s e w ill
• b e n e f it y o u r c u r r e n t a n d /o r fu tu re e m p lo y m e n t a s a la n g u a g e te a c h e r in A lb e rta ?
• b e n e f it th e s c h o o l,
• h o w y o u p la n to s h a r e th is k n o w e ld g e w ith c o lle a g u e s , a n d
• i f n o t c u r r e n tly te a c h in g a la n g u a g e o th e r th a n E n g lis h , in d ic a te w h e n y o u w o u ld b e r e a d y to te a c h th e la n g u a g e y o u
w ill b e s tu d y in g .

Estimated Expenses

1. Tuition: ___________ 2. Travel: ------------------ 3. Accommodation:------------------ Meals:

Total (in Canadian funds): __________________

In c lu d e a s e p a r a te s h e e t to e x p la in a n y e x c e p tio n a l o r u n u s u a l e x p e n s e s o r o th e r f in a n c ia l c o n d itio n s th a t y o u w o u ld
lik e to b r in g to th e c o m m it te e ’s a tte n tio n .

A re y o u a p p ly in g fo r fu n d in g fr o m a n o th e r s o u r c e s to ta k e th is p r o g r a m ? Y e s _____ N o ______
I f y e s , p le a s e in d ic a te th e a m o u n t a n d ty p e o f s u p p o r t, e .g . a c c o m m o d a tio n , m e a ls , e tc .

D o y o u a n tic ip a te r e c e iv in g fu n d in g fro m a n o th e r s o u r c e to p a r tic ip a te in th is p r o g r a m ? Y es No

I f y e s , p le a s e in d ic a te th e a m o u n t a n d ty p e o f s u p p o r t, e .g . a c c o m m o d a tio n , m e a ls , e tc .
 Please attach a resume including your education and work history.

Language Teaching Experience: List all language courses and grade level you have taught in the last five years
beginning with your current teaching assignment:

Courses/Grade Level Description School Year

Language Learning: List your formal language learning i.c. language courses, program, dcgrcc(s) completed, etc.:

Courses/Program Offered by: Year

Check all boxes that apply to you:

Q N e w to s e c o n d la n g u a g e te a c h in g D R e tu rn in g to te a c h a la n g u a g e a f te r s o m e tim e EH C u rre n tly te a c h in g th is la n g u a g e
Q N e w to le a r n in g th is la n g u a g e * Q A flu e n t s p e a k e r Q A la n g u a g e e x p e r t (la n g u a g e
* m u s t h a v e b e g u n s tu d y o f th is la n g u a g e in A lb e rta le a d /m a s te r te a c h e r)

Language Background: W h a t is th e la n g u a g e y o u a re m o s t p r o f ic ie n t i n ? _________________________________________

Indicate level of proficiency in all languages other than English: E xcellent, Good, Fair, N eeds im provem ent: _____
Languages:
R e a d in g :
W ritin g :
S p e a k in g

Professional Development Summary:

In c lu d e a re s u m e a n d a tta c h a b r i e f s u m m a ry o u tlin in g a ll r e le v a n t p ro f e s s io n a l d e v e lo p m e n t y o u h a v e c o m p le te d in th e la s t
fiv e y e a rs . E n s u re to o u tlin e y o u r r e c e n t e ff o rts to e n h a n c e a n d /o r d e v e lo p :
• y o u r s k ills in th is la n g u a g e
• y o u r p e d a g o g ic a l a n d /o r le a d e rs h ip s k ills in th e a re a o f la n g u a g e te a c h in g , a n d
• h o w th is c o u rs e w ill fit in to y o u r d e v e lo p m e n t/g r o w th p la n .

Page 334
 Declaration of Applicant

I HAVE READ THE INSTRUCTIONS, AND DECLARE THAT:

(a ) I h a v e a n s w e r e d a ll q u e s tio n s a p p lic a b le to m e a n d th a t all in f o rm a tio n is tr u e a n d c o m p le te ;

(b ) I p r o p o s e to ta k e th e c o u r s e n a m e d fo r th e p e r io d s ta te d ;
(c ) I w ill n o tify A lb e rta S c h o la r s h ip P r o g r a m s s h o u ld I w ith d r a w fro m s tu d ie s ;
(d ) I a g r e e to a llo w m y n a m e , c ity /to w n , p r o g r a m in f o r m a tio n , s c h o o l, a n d ju r is d i c ti o n to b e r e le a s e d to th e
m e d ia a n d a p p r o p r ia te M e m b e r s o f th e L e g is la tiv e A s s e m b ly (M L A s ) i f I re c e iv e th is a w a rd ; a n d ,
(e ) I a u th o r iz e th e r e le a s e a n d e x c h a n g e o f p e rs o n a l in f o rm a tio n b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d
A lb e rta E d u c a tio n a n d a n y fe d e ra l a n d p r o v in c ia l g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e
in f o rm a tio n I h a v e p r o v id e d to A lb e rta S c h o la r s h ip P r o g r a m s a n d fo r th e u s e in re s e a rc h a n d s ta tis tic a la n a ly s is in
p ro g r a m e v a lu a tio n a n d p r o g r a m p ro m o tio n .

Signature of Applicant (in ink) Today’s Date (in ink)

Applicant Checklist

A p p lic a tio n is c o m p le te d in its e n tir e ty a n d th e following documents are attached:

□ P ro g r a m /C o u rs e S y lla b u s in E n g lis h
□ S ta te m e n t o f In te n t
□ P ro f e s s io n a l D e v e lo p m e n t S u m m a ry
□ R esu m e

] A p p lic a tio n is s ig n e d , d a te d a n d c o m p le te d in in k .

] E n tire a p p lic a tio n p a c k a g e in c lu d in g y o u r c u r r e n t s u p e r v is in g a d m i n is tr a t o r ’s e n d o r s e m e n t ( S c h o o l A u th o rity

E n d o r s e m e n t - P a rt 1) is fo r w a rd e d to y o u r lo c a l s c h o o l a u th o r ity c o n ta c t** fo r re v ie w .

Notes to Applicant

Submit your completed application to your local school authority. The local school authority will mail your
application package to Alberta Scholarship Program. Please allow sufficient time to the local school authority' to
complete their endorsement in order to meet the February 10 application deadline.

DO NOT SUBMIT YOUR APPLICATION TO ALBERTA SCHOLARSHIP PROGRAMS

INCOMPLETE APPLICATION WILL NOT BE CONSIDERED

*C o n ta c ts f o r th e M e tro B o a rd s :
Calgary Board of Education: Global Learning Services
Calgary Catholic School District: Supervisor, French and International Languages
Edmonton Public Schools: Manager, Staff Development, Fluman Resources Consulting
Edmonton Catholic Schools: Manager, Staffing, Fluman Resources Services

Page 335
 School Authority Endorsement - Part 1
To be Completed by Applicant’s Current Supervising Administrator
T he S elec tio n C o m m ittee need s clear a n d co n cise in fo rm a tio n o n y o u r la n g u a g e p ro g ra m n eed s a t y o u r sc h o o l a n d h o w it is exp e c te d
th e a p p lica n t's s u m m e r p ro g ra m w ill b e n e fit th e sc h o o l a n d m e e t th e s c h o o l’s la n g u a g e needs. F e e l f r e e to attach a d d itio n a l in fo rm a tio n on th e
a p p lic a n t a n d /o r th e s c h o o l’s la n g u a g e needs.

NAME OF APPLICANT: ____________________________________________________

W h a t is th e a n tic ip a te d a s s ig n m e n t o f th is a p p lic a n t in th e 2 0 1 5 /2 0 1 6 s c h o o l y e a r ? ( c o u r s e s , g ra d e , e tc .)

W ill th e a p p lic a n t b e te a c h in g a la n g u a g e o th e r th a n E n g lis h ? I f s o , p le a s e in d ic a te w h a t la n g u a g e ___________________________

i f n o t te a c h in g a la n g u a g e o th e r th a n E n g lis h , h o w w ill th e a p p li c a n t’s p a r tic ip a tio n b e n e f it y o u r s c h o o l a n d th e s c h o o l d iv is io n ?

T h e a p p lic a n t w ill b e:
_____ re tu r n in g to th e s a m e s c h o o l te a c h in g a t a n o th e r s c h o o l ___________
_____ ta k in g o n a n e w a s s ig n m e n t re tu r n in g to th e s a m e a s s ig n m e n t
_____ u n s u r e a t th is tim e o th e r

H o w lo n g h a s th is a p p lic a n t b e e n u n d e r y o u r s u p e r v is io n ? ______________________________________

W h a t la n g u a g e p r o g r a m s /p r o je c ts /in itia tiv e s h a s th is a p p lic a n t le d o r a s s is te d w ith w h ile u n d e r y o u r s u p e r v is io n ?

T h is s c h o o l n e e d s ( c h e c k th e m o s t a p p ro p r ia te ): T h is a p p lic a n t is ( c h e c k o n e ):

_____ a le a d /m a s te r te a c h e r in th is la n g u a g e a le a d /m a s te r t e a c h e r in th e c h o s e n la n g u a g e
_____ th is te a c h e r to r e f r e s h /e n h a n c e s k ills a te a c h e r re tu rn in g to te a c h in g la n g u a g e s
_____ a te a c h e r f o r th is s e c o n d la n g u a g e __ n e w to te a c h in g th is la n g u a g e
__ n e w to la n g u a g e le a r n in g

H o w w ill s tu d e n ts in y o u r s c h o o l b e n e f it fr o m th e a p p li c a n t’s e x p e rie n c e ?

H o w w ill th is s u m m e r la n g u a g e p r o g r a m fit in to th is t e a c h e r ’s p ro f e s s io n a l d e v e lo p m e n t p la n a n d h o w w ill it fit in to y o u r s c h o o l’s

la n g u a g e p la n ?

N a m e & P o s itio n ( p le a s e p r in t) S ig n a tu re (in in k ) T o d a y ’s D a te

N a m e o f S c h o o l:_______________________________________________ S c h o o l L o c a tio n : ________________________________________

N a m e o f P rin c ip a l: ______________________________________________________________ P h o n e N u m b e r: _________________________

Application Deadline: February 10

 School Authority Endorsement - Part 2
To be Completed by Applicant’s Superintendent or School Jurisdiction Key Contact
T h e S elec tio n C o m m ittee n e e d s clear a n d co n cise in fo rm a tio n on th e la n g u a g e p ro g ra m n e e d s in y o u r sc h o o l division a n d h o w it is e x p e c te d th e
a p p lic a n t’s s u m m e r p ro g ra m w ill b e n e fit th e sc h o o l a n d m e e t th e sc h o o l d iv is io n ’s la n g u a g e needs. F e e l f r e e to attach a d d itio n a l in fo rm a tio n on
th e a p p lica n t a n d /o r th e sc h o o l's la n g u a g e needs.

NAME OF APPLICANT: ___________________________________________

T h is a p p li c a n t’s p a r tic ip a tio n in th e d e s c r ib e d la n g u a g e p r o g r a m w ill s u p p o r t th e s c h o o l a u th o r it y ’s la n g u a g e p la n b y (c h e c k

a p p r o p r ia te s ta te m e n t(s ) - a tta c h e a d d itio n a l in f o ra m tio n a s n e e d e d :
_____ e n h a n c in g th e la n g u a g e e x p e r tis e a lr e a d y a v a ila b le in th e d is tric t
_____ b e g in n in g to d e v e lo p d is tric t e x p e r tis e in th is la n g u a g e
_____ p r o v id in g m u c h n e e d e d le a d e rs h ip to th is s c h o o l
_____ m e e tin g a s ta ffin g n e e d th r o u g h in - s e rv ic e d e v e lo p m e n t o f th is t e a c h e r ’s la n g u a g e s k ills
_____ b e g in n in g th e jo u r n e y o f d e v e lo p in g la n g u a g e p ro g r a m m in g

H o w w ill th e e x p e r ie n c e a n d s k ills a c q u ir e d b y th is a p p lic a n t p a r tic ip a tin g in th is p a r tic u la r p r o g r a m b e n e fit th e s c h o o l a n d s c h o o l

a u th o r ity ?

W h a t is im p o r ta n t fo r th e s e le c tio n c o m m itte e to k n o w a b o u t:
- th is a p p lic a n t?
- th e la n g u a g e s t a f f n e e d s o f th is s c h o o l?
- th e la n g u a g e p r o g r a m n e e d s fo r y o u r s c h o o l a u th o r ity /d iv is io n /d is tr ic t?
- o th e r k e y c o n s id e r a tio n ?

N a m e (p le a s e p rin t) S ig n a tu re (in in k ) T o d a y ’s D a te

P o s itio n S c h o o l A u th o r ity N a m e Phone N um ber

F A X E D A P P L IC A T IO N S A R E N O T A C C E P T E D

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e rta T 5 J 4 R 4 E d m o n to n , A lb e rta T 5 K .2 V 1

Telephone: 7 8 0 .4 2 7 .8 6 4 0
Email: s c h o la rs h ip s @ g o v .a b .c a
Website: w w w .a lis .a lb e r ta .a b .c a /s c h o la r s h ip s

Application Deadline: February 10

 Laurence Decore
Award for
Student Leadership

Page
 LAURENCE DECORE
AWARD FOR STUDENT LEADERSHIP
T h e L a u re n c e D e c o re A w a rd fo r S tu d e n t L e a d e rs h ip h o n o u r s M r. L a u re n c e D e c o re , fo r m e r E d m o n to n m a y o r a n d le a d e r o f th e
A lb e r ta L ib e ra l p a rty .

T h e o rig in a l p ro p o s a l fo r th e S tu d e n t L e a d e rs h ip A w a rd s w a s in itia te d b y th e A lb e rta C o lle g e & T e c h n ic a l I n s titu te S tu d e n t

E x e c u tiv e C o u n c il ( A C T I S E C ). T h e A w a rd s a re in te n d e d to re c o g n iz e th o s e p o s t- s e c o n d a r y s tu d e n ts w h o h a v e d e m o n s tr a te d
o u ts ta n d in g d e d ic a tio n a n d le a d e rs h ip to f e llo w s tu d e n ts a n d to th e i r c o m m u n ity .

Award Value - $1,000

Eligibility Criteria
N o m in e e s m u s t:
a. b e a C a n a d ia n C itiz e n o r P e rm a n e n t R e s id e n t a n d b e a n A lb e r ta re s id e n t,
b. b e c u r r e n tly e n ro lle d fu ll-tim e (a m in im u m 6 0 % c o u rs e lo a d ) in a n u n d e r g r a d u a te p r o g r a m a t a d e s ig n a te d A lb e rta
in s titu tio n ,
c. in v o lv e d in e ith e r s tu d e n t g o v e r n m e n t o r s tu d e n t s o c ie tie s , c lu b s o r o r g a n iz a tio n s , o r in v o lv e d in s tu d e n t o r g a n iz a tio n s at
th e p r o v in c ia l o r n a tio n a l le v e l o r in n o n - p r o f it c o m m u n ity o rg a n iz a tio n s , a n d b e
d. r e c o m m e n d e d b y a S e le c tio n C o m m itte e a t th e e d u c a tio n a l in s titu tio n .

Nomination Procedure
E a c h in s titu tio n is re s p o n s ib le fo r e s ta b lis h in g a S e le c tio n C o m m itte e to re v ie w n o m in a tio n s .

N o m in a tio n s s h o u ld b e s u b m itte d d ir e c tly to th e S e le c tio n C o m m itte e b y M a r c h l . P le a s e n o te th a t in s titu tio n s m a y im p o s e a n

e a r lie r d e a d lin e .

T h e S e le c tio n C o m m itte e w ill fo r w a rd th e n a m e s o f s u c c e s s fu l c a n d id a te s to A lb e rta S c h o la r s h ip P r o g r a m s b y M a r c h 15.

T h e a w a rd s a re d is b u r s e d a f te r A p ril 1.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e rta T 5 K .2 V 1

T e le p h o n e : 7 8 0 .4 2 7 .8 6 4 0
E m a il: s c h o la rs h ip s @ g o v .a b .c a
W e b site : a lis .a lb e r ta .c a /s c h o la r s h ip s

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Page 339
 LAURENCE DECORE
AWARD FOR STUDENT LEADERSHIP
W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F re e d o m o f In fo rm a tio n a n d P ro te c tio n
o f P riv a c y A c t (F O IP A ct), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H eritag e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
: c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F lo o r-9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 J 4 R 4 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .
V ^pleasei

c Return the completed form the Student Union or Student Association Office by March 1

Personal Information
3

/ A lb e rta S tu d e n t N u m b e r (go to www.education.gov.ah.ca to find your ASN or to obtain one) S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current legal name) Please use upper and lower case. F ir s t N a m e current legal name)

M a ilin g A d d r e s s (Include Apt, or Box Number) C ity /T o w n

P re v io u s S u rn a m e
P ro v in c e P o s ta l C o d e A re a C o d e fele p h o n e N u m b e r

B irth D a te G e n d e r (circle one) E m a il A d d re s s

M
J___ I___ L
day month year

CITIZENSHIP (check one)

] C A N A D IA N C IT IZ E N or [ ^ P E R M A N E N T R E S I D E N T (L a n d e d Im m ig ra n t)
Note: Include a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e rta ?
Y N

H a v e y o u liv e d in A lb e rta a ll y o u r life ?

Y N
IF YOU ANSWERED “NO” TO BOTH QUESTIONS, PLEASE INCLUDE A
SinCe I I I I I LETTER EXPLAINING WHAT YOU HAVE DONE SINCE ARRIVING IN
month year ALBERTA, e.g. attending school, working, etc.
POST-SECONDARY STUDIES
N a m e o f In s titu tio n

L o c a tio n E n try D a te o f P ro g ra m _

Office Use Only

89 8 0 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR
Disbursement

$ 1,000 MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: April 2014

Page 340
 PLEASE GIVE A DETAILED DESCRIPTION OF THE INVOLVEMENT (e.g. ORGANIZATION, POSITION,
RESPONSIBILITIES) AS WELL AS THE MOST SIGNIFICANT ACCOMPLISHMENTS OF THE INDIVIDUAL BEING
NOMINATED. (Additional sheets may be appended)

V J

Declaration of Applicant
h a v e r e a d a n d u n d e r s ta n d th e in s tr u c tio n s , a n d d e c la r e th a t:
" \
a. a ll in f o r m a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a f u ll-tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tify A lb e rta S c h o la r s h ip P r o g r a m s in w r itin g i f 1 w ith d r a w fro m fu ll-tim e s tu d ie s b e fo r e
c o m p le tin g o n e s e m e s te r.

I u n d e r s ta n d a n d a g re e th a t:
a. m y p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic r e c o r d s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e rta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u rp o s e o f d e te r m in in g m y e lig ib ility fo r a
s c h o la rs h ip ,
b. m y p e rs o n a l in f o rm a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e rta S c h o la r s h ip P r o g r a m s a n d a n y p ro v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a rd s o r in s titu tio n s to v e rify th e in f o rm a tio n I h a v e p r o v id e d to A lb e rta S c h o la r s h ip P r o g r a m s a n d
fo r th e u s e in re s e a rc h a n d s ta tis tic a l a n a ly s is in p ro g r a m e v a lu a tio n .

I U N D E R S T A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a rd a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r th is is n o t a
c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d I w ill c o n ta c t A lb e rta S c h o la r s h ip P ro g ra m s .

Signature of Applicant (in ink) Today’s Date (in ink)

V J
Page 341
f \
NOMINATED BY:

Name of Nominator (please print) Address

( A
TO BE COMPLETED BY THE POST-SECONDARY INSTITUTION

I hereby declare that this student has been selected for a Laurence Decore Award for Student Leadership
and is currently enrolled or was enrolled full-time, i.e. taking a minimum of a 60% full course load at
this institution for one semester during the current academic year - September to April.

Name (please print) Position

Signature

NOTE: The award certificate will be mailed to the post-secondary institution after April 1. If it is required for
an award ceremony before April 1st, please submit the nomination form to Alberta Scholarship
Programs at least ten working days prior to the award ceremony. The cheque is mailed directly to the
student.

If you are having an awards ceremony, please indicate the date: ______________________________

V. J

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alb erta.ca/sch olarsh ip s

Page 342
 Student Aid Alberta Online Services
Request Change to Access Data

Complete this form when a student has attempted to access the Student Aid Alberta Online Services
(SFS), and the system is not recognizing their Alberta Student Number (ASN).

Email the completed form to Learner Funding Processing at: lf.processing@ gov.ab.ca

Required Information:

Social Insurance Number:

Alberta Student Number:

Student’s Last Name: ______

Student’s First Name: ______

Date of Birth ______

(dd/mm/yyyy)

Gender: □ Male □ Female

m Student A id Alberta

Page 343
Government of Alberta
Student Aid Alberta Memorandum

FROM: Launa LeBeau DATE:

Director, Student Services
Student Aid

TO: Maggie DesLauriers

Executive Director
Student Aid

REQUEST FOR LEVEL2 EXECUTIVE REVIEW

STUDENT NAME
SIN
INSTITUTION
PROGRAM
TERM DATES
YEAR OF STUDIES
STUDENTS AGGREGATE
LTM FOR PROGRAM
DATE RFR RECEIVED

Reason for Level 2 Review:

CIRCUMSTANCES:

Policv/Legislation:

RECOMMENDATIONS:

Level 2 Review R ^344

Reviewed by:

Sue Ostashek, Assessing Manager Date

Reviewed & Recommended by:

Launa LeBeau, Director, Student Services Date

Comments:

RECOMMENDATION

□ DECLINED □ APPROVED □ MODIFIED AS FOLLOWS

Maggie DesLauriers, Executive Director, Student Aid Date

Level 2 Review R ^® 345

y^Jaerbcai Manager Review
S tudent A id Alberta

DATE January 29, 2016

STUDENT NAME
SIN
INSTITUTION
PROGRAM
TERM DATES
YEAR OF STUDIES
STUDENTS AGGREGATE
LTM FOR PROGRAM

REASON FOR REVIEW

THE STUDENT REVIEW OF THEIR AWARD IS

Q DECLINED □ APPROVED □ MODIFIED AS FOLLOWS

Signatures
Manager Date

Director (if required) Date

Page 346
Maria Sava Polish Heritage
Awards and Scholarships
 MARIA SAVA POLISH HERITAGE AWARDS AND SCHOLARSHIPS
T h e s e a w a r d s a n d s c h o la r s h ip s r e c o g n iz e th e e x c e lle n c e o f s tu d e n ts fr o m th e J a n P a w e l II P o lis h B ilin g u a l P r o g r a m o f E m o n to n
C a th o lic S c h o o ls a n d a s s is t th e m in c o n tin u in g th e i r e d u c a tio n a t th e p o s t- s e c o n d a r y le v e l. T h e p r o g r a m w a s n a m e d in m e m o ry o f
M a r ia S a v a , w h o w a s in s tru m e n ta l in e s ta b lis h in g th e b ilin g u a l p r o g r a m a n d ta u g h t a t th e s c h o o l fo r o v e r 2 0 y e a rs .

Award Value
Three scholarships and two awards of $1,000 each

Eligibility Criteria
A p p lic a n t m u s t:
a. b e a C a n a d ia n c itiz e n o r a P e r m a n e n t R e s id e n t,
b. b e a n A lb e r ta r e s id e n t,
c. h a v e ta k e n a ll o f G ra d e s 7 , 8 a n d 9 a t J a n P a w e l II s c h o o l, a n d
d. e n ro ll fu ll-tim e a n a n y p r o g r a m o f s tu d y a t th e p o s t- s e c o n d a r y le v e l.

S tu d e n ts n o r m a lly a p p ly in th e y e a r th e y g ra d u a te fr o m h ig h s c h o o l. I f a s tu d e n t m is s e s th e d e a d lin e th e y m a y a p p ly in a s u b s e q u e n t
y e a r. R e c ip ie n ts n c a n o n ly re c e iv e th e a w a rd o n c e .

Selection Criteria
T h e three scholarship recipients w ill b e s e le c te d o n th e b a s is o f a c a d e m ic e x c e lle n c e a s c a lc u la te d fr o m th e fin a l s ta n d in g s in fiv e
c o u rs e s in G r a d e 12 u s in g th e A le x a n d e r R u th e r f o r d S c h o la r s h ip c o u rs e c r ite r ia a s fo llo w s :

One of: E n g lis h 3 0 , E n g lis h 3 0 - 1 , 3 0 - 2 o r F r a n c a is 3 0 , 3 0 -2 a n d

At least two of: P u re M a th e m a tic s 3 0 A p p lie d M a th e m a tic s 3 0 M a th e m a tic s 31

M a th e m a tic s 31 S c ie n c e 3 0 M a th e m a tic s 3 0 -1 , o r 3 0 -2
B io lo g y 3 0 C h e m is tr y 3 0 P h y s ic s 3 0
S o c ia l S tu d ie s 3 0 , 3 0 -1 o r 3 0 -2 o r a la n g u a g e o th e r th a n th e o n e u s e d a b o v e a t th e G ra d e 12 le v e l

Any other two courses w ith a m in im u m fiv e c re d it v a lu e a t th e G ra d e 12 le v e l (3 0 0 0 o r 6 0 0 0 s e r ie s ) in c lu d in g th o s e lis te d a b o v e

a n d c o m b in e d a d v a n c e d C T S c o u rs e s .

T h e two award recipients w ill b e s e le c te d b y th e a d m in is tr a tio n a t J a n P a w e l II S c h o o l, a n d s e le c tio n w ill b e b a s e d o n in te rn a l

c rite ria .

Application Procedure

A p p lic a n ts w ill b e n o tifie d o f th e s ta tu s o f th e i r a p p lic a tio n in S e p te m b e r. T h e a w a rd w ill b e is s u e d in N o v e m b e r a f t e r A lb e r ta

S c h o la r s h ip P r o g r a m s c o n f ir m s th e r e c i p ie n t’s fu ll-tim e e n r o lm e n t a t a p o s t- s e c o n d a r y in s titu tio n .

FAXED OR SCANNED APPLICATIONS ARE VOT ACCEPTED

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2V 1

T e le p h o n e : 7 8 0 .4 2 7 .8 6 4 0
E m a il: s c h o la rs h ip s @ g o v .a b .c a
W e b s ite : a lis .g o v .a b .c a /s c h o la r s h ip s

A p p lication D eadline: J u ly l

Page 348
 MARIA SAVA POLISH HERITAGE AWARDS AND SCHOLARSHIPS
W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F re e d o m o f In fo rm a tio n a n d P rotect,
o f P rivacy’ A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e S c h o la r s h ip ,
a n d to a d m in is te r th e A lb e r ta S c h o la r s h ip P ro g ra m s . I f y o u h a v e a n y q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tii
p le a se c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F lo o r, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information
A lb e rta S tu d e n t N u m b e r H ig h S ch o o l C o d e S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current full legal name) Please use upper and lower case. F ir s t N a m e a n d O n e In itia l (current full legal name)

M a ilin g A d d r e s s (Include Apt. or Box Number) C ity /T o w n

P re v io u s S u rn a m e
P r o v in c e C o u n tr y P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

G e n d e r (circle one) B irth d a te E m a il A d d re s s

M day month year
____l____ ____ I____ ____L___I____ I____

DID YOU COMPLETE ALL OF GRADE 7, 8 AND 9 AT JAN PAWEL II SCHOOL? [^ ]

CITIZENSHIP ( c h e c k o n e )
CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.

ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e r ta ? D id y o u r p a r e n ts liv e in A lb e r ta w h ile y o u w e r e in h ig h s c h o o l?
Y N Y N

H a v e y o u liv e d in A lb e r ta a ll y o u r life ?
IF YOU ANSWERED ‘NO’ TO EITHER OF THESE QUESTIONS
Y N S in c e month year PLEASE INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
____I________ I__ _J____ I____

PROPOSED POST-SECONDARY STUDIES

N a m e o f In s titu tio n In s titu tio n C o d e (Note: See back page for institution codes.)

In s titu tio n C ity E n try D a te fo r P r o g r a m P ro g ra m

month . year .

P O S T - S E C O N D A R Y S T U D E N T I.D . N U M B E R

Office Use Only

Revised: June 2013

Page 349
 Personal Information (continued)

SECONDARY EDUCATION
N a m e o f H ig h S c h o o l

T o w n /C ity P ro v in c e

D a te o f C o m p le tio n o f H ig h S c h o o l H a v e y o u a p p lie d fo r a n A le x a n d e r R u th e rf o rd S c h o la r s h ip ?
Y N I f ‘Y E S ’ w h a t y e a r?
___ 1___ 1
___ l___ 1___ 1___
year

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T I O N S , A N D D E C L A R E T H A T :
a. a ll in f o r m a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d fo r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tif y th e o ff ic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r it in g i f I w ith d r a w fr o m fu ll-tim e s tu d ie s b e fo r e
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D ER ST A N D A N D A G R E E THAT:
a. p e rs o n a l in f o rm a tio n p e r ta in in g to m y h ig h s c h o o l a c a d e m ic re c o r d m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e rta
E d u c a tio n a n d A lb e r ta S c h o la r s h ip P r o g r a m s f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ,
b. p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u rp o s e o f d e te r m in in g m y e lig ib ility f o r a
s c h o la rs h ip ,
c. m y p e rs o n a l in f o r m a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y p r o v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o rm a tio n I h a v e p r o v id e d to A lb e r ta S c h o la r s h ip P ro g r a m s , a n d
f o r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D ER ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e re le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is n o t a
c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g r a m s .

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
I f y o u r in s titu tio n c o d e is n o t lis te d h e re , c h e c k th e in s titu tio n c o d e lis tin g a t .alis.gov.ab.ca/ndf/scholarships/codes.pdf.

U n iv e r s ity o f A l b e r t a ................................2 2 0 1 C o n c o r d ia U n iv e r s ity C o lle g e ( A B ) ..2 2 4 6 M o u n t R o y a l U n iv e r s ity 2243

U n iv e r s ity o f C a l g a r y .............................. 2 2 0 2
U n iv e r s ity o f L e t h b r i d g e ........................2 2 0 3
N A I T ................................................................. 2 2 2 1
S A I T ................................................................. 2 2 2 2
A lb e r ta C o lle g e o f A r t & D e s ig n .......5 1 1 0
A m b ro s e U n i v e r s i t y ................................. 9 0 4 1
A th a b a s c a U n iv e r s ity ................................2 2 0 4
B o w V a lle y C o l l e g e .................................. 2 2 1 8
D e v r y I n s titu te o f T e c h n o lo g y .............. 2 0 4 0
G ra n d e P ra irie R e g io n a l C o ll e g e .........2 2 4 1
G r a n t M a c E w a n U n i v e r s i t y ................... 2 2 4 7
K e y a n o C o l l e g e ............................................2 2 3 0
K in g s U n iv e r s ity C o l l e g e ........................2 2 5 5
L a k e la n d C o l l e g e ......................................... 2 2 2 5
L e th b r id g e C o l l e g e ..................................... 2 2 2 0
M e d ic in e H a t C o l l e g e ................................2 2 4 2
N o r th e r n L a k e s C o ll e g e e ........................ 2 0 2 0
N o r q u e s t C o l l e g e ........................................2 2 2 6
O ld s C o l l e g e ................................................. 2 2 2 4
P o rta g e C o l l e g e ............................................2 2 1 9
R e d D e e r C o ll e g e ........................................2 2 4 4
S t. M a r y ’s ........................................................ 5661
T a y lo r U n i v e r s i t y ........................................2 2 6 8

Page 350
 Required Information for a
11 PO Box 28000 Stn Main
V H Edmonton AB T5J 4R4 Correspondence/E-learning/
Student A id Alberta Distance Study Program
Students should submit this form only when they receive a request to do so from Student Aid Alberta.

Student Name: Program of Study:

Social Insurance Number:
To the Student
Under the Pan Canadian Designation Policy Framework there are specific requirements that must be met for
students requesting full-time funding when enrolled in a correspondence/e-learning/distance delivered program.
In order to determine whether you are eligible to receive full-time funding, please work with the Registrar’s Office
to complete this form. Then return the form via mail to the above address or fax it directly to (780) 422-4516.

To the School Official - please provide answers to the following questions:

1) Can students enrolled in this correspondence/e-learning/distance program be considered registered full­
time by your institution? □ Yes □ No
If yes, provide the credit/hour requirements for full-time enrollment: _______________________________

2) Are all of the courses within this correspondence/e-learning/distance program offered in a specified time
frame (with a definite start and end date)? □ Yes □ No

3) How are students monitored to ensure that academic progress and minimum full-time course loads are
being maintained?__________________________________________________________________________

4) W hat procedure does your institution have in place for those students who are not progressing?

5) Are students completing a minimum of 20 hours per week of student activity or participation?
□ Yes □ No

6) Are your residents eligible to apply for full-time financial assistance through the relevant student funding
authority? □ Yes □ No

7) Does the correspondence/e-learning/distance division of your institution operate under separate

administration and financial aid offices from the main institution? □ Yes O N o

To the School Official - please complete

Signature of School Official *Email address ('required)

Title/Position Date

April 2013

Page 351
 Memorandum

FROM: Andre Tremblay DATE:

Executive Director TELEPHONE: 780-422-4498
Innovation and Advanced Education REFERENCE:
Apprenticeship and Student Aid

TO: Peter Leclaire

Assistant Deputy Minister
Innovation and Advanced Education
Apprenticeship and Student Aid
STUDENT APPEAL OF THEIR COMPLIANCE AUDIT AND RESULTING OVER-AWARD
SUBJECT
INSTITUTION

REASON FOR REASSESSMENT

PERIOD(S) REASSESSED

AMOUNT OF OVER-AWARD

CIRCUMSTANCES:

REASON FOR APPEAL

AUDITOR/MANAGER
RECOMMENDATION(S)

PREPARED BY

Page 352
Student Last/First Name Ministerial Appeal Page 1
 Review ed/R ecom m ended by:

Hal M arcellin, A cting M anager, Program Compliance & Investigations Date

Review ed/R ecom m ended by:

Andre Trem blay, Executive D irector, A pprenticeship and Student Aid Date

The Decision
(Check one - add com m ents if any)____________________________

□ THE STUDENT APPEAL OF THEIR OVER-AWARD IS DECLINED

□ THE STUDENT APPEAL OF THEIR OVER-AWARD IS APPROVED

□ THE STUDENT APPEAL OF THEIR OVER-AWARD IS MODIFIED AS FOLLOWS:

Peter Leclaire, Assistant D eputy M in is te r Date

A pprenticeship and Student Aid

Docum ents enclosed:

Page 353
Student Last/First Name Ministerial Appeal Page 2
 Post-Secondary
« o Missing Information Request
^< (yP 4 W \X K Ji Student Aid Alberta 3 ~

day month year

Social Insurance Number

App. I.D. Assessor

Return to Assessor
After Cancellation

A ll A p p lic a tio n s General

A8 B1

D o cum e n ta tio n Required

AD AE AF AG C1 C2 C4 C6 C7 CB CD DO D5 D6 D7 D8 DA DB

ASN N um ber Part im e

DE DF B2

C u rricu lu m /T ra n scrip ts /P ro g ra m D efaults

E3 E8 E9 EC F7 H4 H9

E xpenses O ther

XX O rig in a l P aragraph:

July 2014 Page 354

 Name:
PO Box 28000 Stn M ain
E d m on ton AB T5J 4R4 Social Insurance Number:
Student A id Alberta

MISSING INFORMATION RESUME - Complete and return with your Information Request Letter
- * l f you aire a perma rient resident, when did you arrive in Canada? Day Mo nth Year
FROM TO EMPLOYED or UNEMPLOYED ATTENDING SCHOOL RESIDENCE ADDRESS
Not Full- Part- Full- Part- (Include C ity and P rovince)
Month Year Month Year NAME & ADDRESS Emp Time Time Prov NAME & LOCATION Time Time Prov

Page 355
 Missing Information Request
^ddbeifaji PO Box 28000 Stn Main
Edmonton AB T5J 4R4 for Marital Status Change
Student Aid Alberta

Marital Status Change

Complete and return with your Information Request Letter
SOCIAL INSURANCE NUMBER ALBERTA STUDENT NUMBER

Name:

Date of Separation:

The child custody arrangements between me and my spouse/partner are as follows:

(Please provide a copy of the court order and proof of payment for the past 4 months, OR a
copy of the maintenance enforcement report.
If you have never had legal documents, you may submit a copy of a written agreement that is
signed by you and the other parent detailing your child support arrangements. The agreement
must include the custody arrangements for your child and proof of child support payments for
the past four months.)

Are you receiving child support or alimony payments?

}
Yes □ No □

1
If yes, how much per month? $ _____________ .00 /per month

Important: You must immediately notify Student Aid Alberta in writing should any of the
above information change.

Applicant’s signature Date

Send d o c u m e n ts e le c tro n ic a lly : 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely
using e-Document Upload
O r M AIL to : Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4

May 2015

Page 356
1. T h is M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t -
A lb e rta (M S F A A -A lb e rta ) is b e tw e e n th e a p p lic a n t f o r
fin a n c ia l a s s is ta n c e , a s id e n tifie d in P a rt A ( “ S tu d e n t" )
a n d H e r M a je s ty th e Q u e e n in r ig h t o f A lb e rta a s
r e p re s e n te d b y th e M in is te r o f In n o v a tio n a n d A d v a n c e d
E d u c a tio n (“ M in is te r " o r “ In n o v a tio n a n d A d v a n c e d
E d u c a tio n ” ), m a d e p u rs u a n t to th e S tu d e n t F in a n c ia l
A s s is ta n c e A c t (A lb e rta ).
In c o n sid e ra tio n o f the M inister provid ing an A lb e rta S tuden t
Loa n u n d e r th is M S F A A -A lb erta, a n d b y s ig n in g P a rt D
b e lo w , th e S tuden t a grees to th e Term s and C o nditio ns
o f th is lo an a greem ent.
This M S FA A -A lberta is com prised of: Part A : Your Inform ation;
Part B: Term s an d C o n d itio n s; Part C: E le ctro n ic Funds
T ra n sfe r; P a rt D: Your A c k n o w le d g e m e n t an d S ignature;
Part E: A d d itio n a l Term s and C o nditio ns.
2. U ntil su ch tim e a s the A lb e rta S tuden t Loan, to g e th e r w ith
in te re st an d a n y o th e r a m o u n ts to be paid b y th e S tuden t to
the M in iste r are paid in full, th e S tuden t a grees:
a. th a t th is A lb e rta S tuden t Loan, to g e th e r w ith any and all
fu n d s o r o th e r fin a n cia l a ssista n ce receive d b y the S tuden t
fro m th e M in iste r p u rsu a n t to th e A lb e rta S tuden t F inance
A cts shall be su b je ct to, g o ve rn e d b y an d form p a rt o f this
M S FA A -A lb erta, a s am e n d e d fro m tim e to tim e, e ntered
in to b e tw e en the S tuden t an d th e M inister,
to use the A lb e rta S tuden t Loan e xclu sive ly fo r the
p u rp o se s of o b ta in in g N e cessities;
th a t th e M in iste r m a y pay a p ortion o r all o f the A lb e rta
S tu d e n t Loa n d ire c tly to the e d u ca tio n a l in stitu tio n listed
on th e S tu d e n t’s A p p lica tio n fo r p a ym e n t o f the S tu d e n t’s
tu itio n an d a n y m a n d a to ry fees;
to pro vid e no tice o f a n y ch a n g e s to th e S tu d e n t's nam e,
a d d re ss, m a rita l o r co m m o n la w partn e r status, finan cial
3.
circu m sta n ce s, a ca d e m ic sta tu s o r s tu d y period, a n y
cha n g e in the ad d re ss o r fin a n cia l circu m sta n ce s o f the
S tu d e n t's spou se/pa rtner, o r to a n y o th e r in form ation
con ta in e d in the A p p lica tio n , in a cco rd a n ce w ith the
in stru ctio n s re la tin g to ch a n g e s o f in fo rm a tio n fo u n d o n the
S tu d e n t A id A lb e rta w e bsite, stu d e n ta id .a lb e rta .ca :
to pro vid e all in fo rm a tio n requested by th e M in iste r w h ich,
in th e M in is te r’s so le discretio n, is re q u ire d to ve rify any
sta te m e n ts m ade in this M S FA A -A lb erta;
to a bide b y all a p p lica b le p ro visio n s o f the A lb e rta S tuden t
F in a n ce A cts. If a n y o f the te rm s o f th is M S FA A -A lb erta
co n flict w ith a n y o f the A lb e rta S tu d e n t F inance A cts, then
th e p ro visio n s o f the a p p lica b le A lb e rta S tuden t F inance
A ct w ill app ly;
g. to re p a y the fu ll a m o u n t o f th e A lb e rta S tuden t Loan,
to g e th e r w ith in te re st and a n y o th e r a m o u n ts to be paid
b y th e S tuden t to th e M inister, in a cco rd a n ce w ith the
p ro visio n s o f th is M S FA A -A lb e rta ; and
h. th a t this M S F A A -A lb e rta sh a ll re vo ke and re p la ce all
p re vio u s ag re e m e n ts th a t the S tuden t m ay h ave entered
in to w ith the M inister pursu a n t to any o f th e A lb e rta
S tu d e n t F in a n ce A cts.
T h e S tuden t d e cla re s that:
a. a ll in fo rm a tio n p rovid ed in th is M S F A A -A lb e rta and in all
o th e r fo rm s an d co m m u n ica tio n s s u b m itte d by th e Studen t
to th e M in iste r is tru e and co m p le te an d the S tuden t
u n d e rsta n d s th a t th e in fo rm a tio n is su b je ct to review
an d a sse ssm e n t b y th e M inister in a cco rd a n ce w ith the
S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb erta); and
b. th e S tuden t has read, und e rsto o d , and a g re e s to be
b o u n d b y a ll the te rm s and co n d itio n s o f th is M SFA A-
A lb e rta in c lu d in g th o s e in P a rt E, w h ich form part o f this
M S F A A -A lb erta, and a ckn o w le d g e s having reta in e d a
c o p y o f th is M S FA A -A lb erta.

T h is M S FA A -A lb erta doe s not specify the actual am ount(s) that w ill be disbursed to you o r the am ount(s) you will be required to repay. The am ount(s) that will be disbursed to you under this M S FA A -A lb erta will
be dete rm in e d base d on nee ds assessm ent(s) o f yo u r A p plication(s) fo r finan cial assistan ce in a ccordan ce w ith federal and provincial legislation an d policies. You will be responsible und e r th is M SFA A-Alberta
fo r paying yo u r A lb e rta Studen t Loan. By sig ning Part D, you free ly p r o v id e y o u r c o n s e n t(s ), c e r tific a tio n ( s ) a n d r a tific a tio n (s ) and y o u a g re e t o a ll th e T e rm s a n d C o n d itio n s set out in the M SFAA-
Alberta. You und erstand that if you fail to sign this M SFA A -A lberta, you w ill not receive a n y finan cial assistance.

Signature Date (dd-mmm-yyyy)

F o r th e p u rp o s e o f v e rify in g th e d a ta p ro v id e d in th e A p p lic a tio n a n d th e M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta , I hereby conse nt to the release, b y C a nada R e venue A g ency to
an official o f Innovation and A d vanced Education, o f in form ation from m y in com e ta x returns and, if applicable, o th e r required ta xp a ye r in form ation a b o u t m e, w h e th e r supp lie d by m e o r b y a third party. The
in form ation w ill be relevant to and used solely fo r the purpose o f determ ining and verifying m y eligibility, entitlem ent fo r and the gen era l adm inistration and enforcem ent o f the student financial assistance program s
und e r the C a nada S tu d e n t L o a n s Act, th e C a n a d a S tu d e n t F in a n c ia l A s s ista n ce Act, the S tu d e n ts F in a n ce A c t (A lb erta), th e S tu d e n t L o a n A c t (A lb erta) an d the S tu d e n t F in a n c ia l A s s is ta n c e A c t (Alberta).
T h is a u th o riza tio n is v a lid fo r the ta xa tio n ye a r p rio r to th e ye a r o f sig n a tu re o f th is co nse nt, th e ye a r o f sig n a tu re o f th is co n se n t an d a n y o th e r s u b se q u e n t ta xa tio n ye a r fo r w h ich a ssista n ce is requested.

Signature Date (dd-mmm-yyyy)

Student Aid Alberta Service Centre CANADA POST STAMP

PO Box 4050 1 855 606-2096 (toll free from anywhere in North America)
Mississauga Stn A 1 855 306-2240 (TTY for the hearing impaired)
Mississauga ON 800 2 529-9242 (outside North America - add the appropriate
L5A 4M9 International Access Code)
Copy 1 - SAASC Copy June 2015
Paife13°Jl5)
1. T h is M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t -
A lb e rta (M S F A A -A lb e rta ) is b e tw e e n th e a p p lic a n t f o r
fin a n c ia l a s s is ta n c e , a s id e n tifie d in P a rt A ( “ S tu d e n t" )
a n d H e r M a je s ty th e Q u e e n in r ig h t o f A lb e rta a s
r e p re s e n te d b y th e M in is te r o f In n o v a tio n a n d A d v a n c e d
E d u c a tio n (“ M in is te r " o r “ In n o v a tio n a n d A d v a n c e d
E d u c a tio n ” ), m a d e p u rs u a n t to th e S tu d e n t F in a n c ia l
A s s is ta n c e A c t (A lb e rta ).
In c o n sid e ra tio n o f the M inister provid ing an A lb e rta S tuden t
Loa n u n d e r th is M S F A A -A lb erta, a n d b y s ig n in g P a rt D
b e lo w , th e S tuden t a grees to th e Term s and C o nditio ns
o f th is lo an a greem ent.
This M S FA A -A lberta is com prised of: Part A : Your Inform ation;
Part B: Term s an d C o n d itio n s; Part C: E le ctro n ic Funds
T ra n sfe r; P a rt D: Your A c k n o w le d g e m e n t an d S ignature;
Part E: A d d itio n a l Term s and C o nditio ns.
2. U ntil su ch tim e a s the A lb e rta S tuden t Loan, to g e th e r w ith
in te re st an d a n y o th e r a m o u n ts to be paid b y th e S tuden t to
the M in iste r are paid in full, th e S tuden t a grees:
a. th a t th is A lb e rta S tuden t Loan, to g e th e r w ith any and all
fu n d s o r o th e r fin a n cia l a ssista n ce receive d b y the S tuden t
fro m th e M in iste r p u rsu a n t to th e A lb e rta S tuden t F inance
A cts shall be su b je ct to, g o ve rn e d b y an d form p a rt o f this
M S FA A -A lb erta, a s am e n d e d fro m tim e to tim e, e ntered
in to b e tw e en the S tuden t an d th e M inister,
to use the A lb e rta S tuden t Loan e xclu sive ly fo r the
p u rp o se s of o b ta in in g N e cessities;
th a t th e M in iste r m a y pay a p ortion o r all o f the A lb e rta
S tu d e n t Loa n d ire c tly to the e d u ca tio n a l in stitu tio n listed
on th e S tu d e n t’s A p p lica tio n fo r p a ym e n t o f the S tu d e n t’s
tu itio n an d a n y m a n d a to ry fees;
to pro vid e no tice o f a n y ch a n g e s to th e S tu d e n t's nam e,
a d d re ss, m a rita l o r co m m o n la w partn e r status, finan cial
3.
circu m sta n ce s, a ca d e m ic sta tu s o r s tu d y period, a n y
cha n g e in the ad d re ss o r fin a n cia l circu m sta n ce s o f the
S tu d e n t's spou se/pa rtner, o r to a n y o th e r in form ation
con ta in e d in the A p p lica tio n , in a cco rd a n ce w ith the
in stru ctio n s re la tin g to ch a n g e s o f in fo rm a tio n fo u n d o n the
S tu d e n t A id A lb e rta w e bsite, stu d e n ta id .a lb e rta .ca :
to pro vid e all in fo rm a tio n requested by th e M in iste r w h ich,
in th e M in is te r’s so le discretio n, is re q u ire d to ve rify any
sta te m e n ts m ade in this M S FA A -A lb erta;
to a bide b y all a p p lica b le p ro visio n s o f the A lb e rta S tuden t
F in a n ce A cts. If a n y o f the te rm s o f th is M S FA A -A lb erta
co n flict w ith a n y o f the A lb e rta S tu d e n t F inance A cts, then
th e p ro visio n s o f the a p p lica b le A lb e rta S tuden t F inance
A ct w ill app ly;
g. to re p a y the fu ll a m o u n t o f th e A lb e rta S tuden t Loan,
to g e th e r w ith in te re st and a n y o th e r a m o u n ts to be paid
b y th e S tuden t to th e M inister, in a cco rd a n ce w ith the
p ro visio n s o f th is M S FA A -A lb e rta ; and
h. th a t this M S F A A -A lb e rta sh a ll re vo ke and re p la ce all
p re vio u s ag re e m e n ts th a t the S tuden t m ay h ave entered
in to w ith the M inister pursu a n t to any o f th e A lb e rta
S tu d e n t F in a n ce A cts.
T h e S tuden t d e cla re s that:
a. a ll in fo rm a tio n p rovid ed in th is M S F A A -A lb e rta and in all
o th e r fo rm s an d co m m u n ica tio n s s u b m itte d by th e Studen t
to th e M in iste r is tru e and co m p le te an d the S tuden t
u n d e rsta n d s th a t th e in fo rm a tio n is su b je ct to review
an d a sse ssm e n t b y th e M inister in a cco rd a n ce w ith the
S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb erta); and
b. th e S tuden t has read, und e rsto o d , and a g re e s to be
b o u n d b y a ll the te rm s and co n d itio n s o f th is M SFA A-
A lb e rta in c lu d in g th o s e in P a rt E, w h ich form part o f this
M S F A A -A lb erta, and a ckn o w le d g e s having reta in e d a
c o p y o f th is M S FA A -A lb erta.

T h is M S FA A -A lb erta doe s not specify the actual am ount(s) that w ill be disbursed to you o r the am ount(s) you will be required to repay. The am ount(s) that will be disbursed to you under this M S FA A -A lb erta will
be dete rm in e d base d on nee ds assessm ent(s) o f yo u r A p plication(s) fo r finan cial assistan ce in a ccordan ce w ith federal and provincial legislation an d policies. You will be responsible und e r th is M SFA A-Alberta
fo r paying yo u r A lb e rta Studen t Loan. By sig ning Part D, you free ly p r o v id e y o u r c o n s e n t(s ), c e r tific a tio n ( s ) a n d r a tific a tio n (s ) and y o u a g re e t o a ll th e T e rm s a n d C o n d itio n s set out in the M SFAA-
Alberta. You und erstand that if you fail to sign this M SFA A -A lberta, you w ill not receive a n y finan cial assistance.

Signature Date (dd-mmm-yyyy)

F o r th e p u rp o s e o f v e rify in g th e d a ta p ro v id e d in th e A p p lic a tio n a n d th e M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta , I hereby conse nt to the release, b y C a nada R e venue A g ency to
an official o f Innovation and A d vanced Education, o f in form ation from m y in com e ta x returns and, if applicable, o th e r required ta xp a ye r in form ation a b o u t m e, w h e th e r supp lie d by m e o r b y a third party. The
in form ation w ill be relevant to and used solely fo r the purpose o f determ ining and verifying m y eligibility, entitlem ent fo r and the gen era l adm inistration and enforcem ent o f the student financial assistance program s
und e r the C a nada S tu d e n t L o a n s Act, th e C a n a d a S tu d e n t F in a n c ia l A s s ista n ce Act, the S tu d e n ts F in a n ce A c t (A lb erta), th e S tu d e n t L o a n A c t (A lb erta) an d the S tu d e n t F in a n c ia l A s s is ta n c e A c t (Alberta).
T h is a u th o riza tio n is v a lid fo r the ta xa tio n ye a r p rio r to th e ye a r o f sig n a tu re o f th is co nse nt, th e ye a r o f sig n a tu re o f th is co n se n t an d a n y o th e r s u b se q u e n t ta xa tio n ye a r fo r w h ich a ssista n ce is requested.

Signature Date (dd-mmm-yyyy)

Student Aid Alberta Service Centre CANADA POST STAMP

PO Box 4050 1 855 606-2096 (toll free from anywhere in North America)
Mississauga Stn A 1 855 306-2240 (TTY for the hearing impaired)
Mississauga ON 800 2 529-9242 (outside North America - add the appropriate
L5A 4M9 International Access Code)
Copy 2 - Your Copy June 2015
Pa¥ a23°Jl5l
Part E Additional Terms and Conditions
D E FIN ITIO N S
4. In th is M S F A A -A lb e rta th e fo llo w in g te rm s s h a ll h a v e th e fo llo w in g m e a n in g s :
a. “A lb e rta S tu d e n t F in a n c e A c ts " m e a n s th e S tu d e n ts F in a n c e A c t (A lb e rta ), th e
S tu d e n t L o a n A c t (A lb e rta ) a n d th e S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb e rta ), a n d
a n y re g u la tio n s m a d e u n d e r th e s e A c ts , e a c h a s m a y b e a m e n d e d fro m tim e to tim e ;
b. “A lb e r ta S tu d e n t L o a n " c o lle c tiv e ly m e a n s a ll lo a n s m a d e to th e S tu d e n t fro m tim e
to tim e p u rs u a n t to a n y o f th e A lb e r ta S tu d e n t F in a n c e A c ts , in c lu d in g lo a n s m a d e
to th e S tu d e n t b y th e M in is te r, lo a n s m a d e to th e S tu d e n t b y a F in a n c in g In s titu tio n
a n d tra n s fe rre d to th e M in is te r, lo a n s m a d e w h ile th e S tu d e n t w a s a m in o r, a n d a ls o
in c lu d in g a n y G ra n t O v e rp a y m e n ts c o n v e rte d to a lo a n b y th e M in is te r u n d e r th e
A lb e r ta S tu d e n t F in a n c e A c ts ;
c. " A p p lic a tio n ” m e a n s a ll a p p lic a tio n s , in th e fo rm p r e s c rib e d b y th e M in is te r,
s u b m itte d b y th e S tu d e n t to th e M in is te r fro m tim e to tim e p u rs u a n t to a n y o f th e
A lb e r ta S tu d e n t F in a n c e A c ts ;
d. “ C o m p le tio n o f S tu d ie s " m e a n s th e la s t d a y o f th e m o n th d u rin g w h ic h th e S tu d e n t
c e a s e s to b e a F u ll T im e S tu d e n t o r P a rt T im e S tu d e n t a n d a fte r w h ic h th e S tu d e n t
d o e s n o t b e c o m e a F u ll T im e S tu d e n t o r P a rt T im e S tu d e n t fo r a c o n tin u o u s p e rio d
o f s ix m o n th s a n d is n o t a P e rs o n o n P a re n ta l L e a v e ;
e. “ F in a n c in g In s titu tio n " m e a n s a fin a n c in g in s titu tio n a s d e fin e d in th e S tu d e n t
F in a n c ia l A s s is ta n c e A c t (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e ;
f. “ F u ll T im e S tu d e n t” m e a n s a S tu d e n t w h o is e n ro lle d in n o t le s s th a n 6 0 % , o r n o t
le s s th a n 4 0 % in th e c a s e o f a S tu d e n t w ith a d is a b ility , o f a fu ll-tim e p ro g ra m
o f s tu d y in th e s e m e s te r in q u e s tio n a t o n e o r m o re p o s t- s e c o n d a r y e d u c a tio n a l
in s titu tio n s , o r h a s th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l A s s is ta n c e
R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h d e fin itio n
p re v a ils in th e e v e n t o f a n y d is c re p a n c y ;
g. “ G ra n t O v e rp a y m e n t" m e a n s a g r a n t o v e r p a y m e n t a s d e fin e d in th e S tu d e n t
F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e ;
h. “ In te re s t F re e P e rio d " m e a n s th e c o n tin u o u s p e rio d c o m m e n c in g w h e n a p e rs o n
b e c a m e a F u ll T im e S tu d e n t o r a P a rt T im e S tu d e n t a n d c o n tin u in g u n til th e la st
d a y o f th e 6 th m o n th fo llo w in g th e m o n th in w h ic h th e p e rs o n c e a s e s to b e s u c h a
s tu d e n t, b u t tre a tin g a n y b r e a k o f 6 m o n th s or, in th e c a s e o f a P e rs o n o n P a re n ta l
L e a v e , 12 m o n th s o r le s s b e tw e e n th e tim e s th e p e rs o n c e a s e d to b e a fu ll-tim e o r
p a rt-tim e s tu d e n t a n d s u b s e q u e n tly b e c a m e a fu ll-tim e o r p a rt-tim e s tu d e n t a g a in a s
n o t b r e a k in g th a t c o n tin u ity , o r h a s th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l
A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h
d e fin itio n p re v a ils in th e e v e n t o f a n y d is c re p a n c y ;
i. “ L o a n P a y m e n t D a te " m e a n s th e d a te o n w h ic h th e S tu d e n t w ill b e re q u ire d to p a y
a m o n th ly in s ta llm e n t a m o u n t to w a r d th e re p a y m e n t o f th e A lb e r ta S tu d e n t L o a n ;
j. “ M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta " o r "M S F A A -A lb e rta "
m e a n s th is lo a n a g r e e m e n t a n d th e A p p lic a tio n ;
k. “N e c e s s itie s " m e a n s th e n e c e s s a ry e x p e n s e s re q u ire d w h ile th e S tu d e n t is a
F u ll T im e S tu d e n t, s u c h a s tu itio n , b o o k s , fe e s , a n d b a s ic liv in g e x p e n s e s ;
l. “ P a rt T im e S tu d e n t" m e a n s a s tu d e n t w h o is e n ro lle d in le s s th a n 6 0 % , o r le s s
th a n 4 0 % in th e c a s e o f a s tu d e n t w ith a d is a b ility , o f a fu ll tim e p r o g ra m in th e
s e m e s te r in q u e s tio n a t o n e o r m o re p o s t s e c o n d a r y e d u c a tio n a l in s titu tio n s o r h a s
th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ),
a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h d e fin itio n p r e v a ils in th e e v e n t o f a n y
d is c re p a n c y ;
m . “ P e rs o n o n P a re n ta l L e a v e " m e a n s : a ) a p a re n t ( w h e th e r b y b lo o d o r a d o p tio n ),
b ) a le g a l g u a rd ia n , o r c ) a n in d iv id u a l w h o b e c o m e s a s te p p a re n t u n d e r
c ir c u m s ta n c e s r e c o g n iz e d b y th e M in is te r, w h o c e a s e s to b e a F u ll T im e S tu d e n t o r
a P a rt T im e S tu d e n t in o rd e r to g iv e b irth to , c a re fo r o r s u p p o rt a c h ild w h o is a n e w
a d d itio n to th e fa m ily b y re a s o n o f b irth , a d o p tio n , le g a l g u a rd ia n s h ip o r th o s e s te p
p a re n t c ir c u m s ta n c e s , a s th e c a s e m a y b e , o r h a s th e m e a n in g p ro v id e d fo r in th e
S tu d e n t F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e
to tim e , w h ic h d e fin itio n p r e v a ils in th e e v e n t o f a n y d is c re p a n c y ;
n. “ P rim e R a te " m e a n s th e v a r ia b le r e fe re n c e r a te o f in te re s t a s c a lc u la te d m o n th ly
b y th e M in is te r b a s e d u p o n th e v a r ia b le r e fe re n c e ra te o f in te re s t d e c la re d b y th e
C a n a d ia n Im p e ria l B a n k o f C o m m e rc e , o r its s u c c e s s o r, a s its ra te fo r C a n a d ia n
d o lla r c o n s u m e r d e m a n d lo a n s ;
o. “ R e p a y m e n t S ta rt D a te ” m e a n s th e d a te th a t th e S tu d e n t’s o b lig a tio n to r e p a y th e
A lb e rta S tu d e n t L o a n , to g e th e r w ith in te re s t, b e g in s , w h ic h is th e firs t d a y o f th e
s e v e n th m o n th fo llo w in g C o m p le tio n o f S tu d ie s ; a n d
p. “S tu d e n t" m e a n s th e b o r r o w e r u n d e r th is M S F A A -A lb e rta w h o h a s s u b m itte d a n
A p p lic a tio n a n d b e e n a p p ro v e d to r e c e iv e fin a n c ia l a s s is ta n c e fro m th e M in is te r.
TERM OF AGREEM ENT
5. T h is M S F A A -A lb e rta s e ts fo rth th e te rm s a n d c o n d itio n s a p p lic a b le to a ll A lb e rta S tu d e n t
L o a n s m a d e to th e S tu d e n t fro m tim e to tim e , a n d s h a ll b e in e ffe c t u n til it is re p la c e d by
a s u b s e q u e n t a g re e m e n t.
O B LIG A TIO N TO IN FO RM
6. T h e S tu d e n t h e re b y a c k n o w le d g e s a n d a g re e s th a t:
a. th e m a k in g o f fa ls e o r m is le a d in g s ta te m e n ts in th is M S F A A -A lb e rta , fa ilu re to
d is c lo s e in fo rm a tio n o r fa ilin g to n o tify o f a n y c h a n g e s to in fo rm a tio n c o n ta in e d in
th is M S F A A -A lb e rta a s r e q u ire d b y th e p ro v is io n s o f th is M S F A A -A lb e rta , m a y re s u lt
in o n e o r m o re o f th e fo llo w in g :
i. th e S tu d e n t b e in g d e n ie d fin a n c ia l a s s is ta n c e ;
Borrower Page 1 - Your Copy
ii. the Student being required to immediately repay the entirety of the Alberta
Student Loan;
iii. the Student being subject to criminal prosecution;
b. the Student shall not apply for or receive financial assistance from another province
or territory for any period of time during which the Student is receiving an Alberta
Student Loan from the Minister; and
c. all funds received by the Student pursuant to the Alberta Student Finance Acts to
which the Student is not entitled under this MSFAA-Alberta, including those resulting
from any administrative errors, shall become a debt due to Her Majesty the Queen
in right of Alberta and may be recovered from the Student by an action in debt.
D IS C L O S U R E O F IN F O R M A T IO N
7. Until such time as the Alberta Student Loan, together with interest and any other amounts
to be paid by the Student to the Minister, is paid in full, the Student acknowledges the
authority of, and where a consent is required, hereby irrevocably authorizes, the Minister
to disclose and exchange the Student’s personal information with:
a. the Government of Canada, the National Student Loans Service Centre, any
provincial, territorial or municipal government department or agency, any lending
institution where the Student may have a student loan, any educational institution,
any landlord, credit bureau or employer for any purpose related to the verification of
information provided by the Student and for administration and enforcement of the
C anada S tu d e n t Loa n s Act, the C anada S tu d e nt F in an cia l A s sista n ce A c t and the
Alberta Student Finance Acts, each as may be amended from time to time;
b. Employment and Social Development Canada through the Social Insurance
Registry to verify the Student’s Social Insurance Number, name, date of birth,
and gender solely to confirm identification for the purpose of financial assistance;
c. Alberta Human Services to operate and administer student financial assistance
programs, including determining the Student's eligibility, and the eligibility of the
Student’s spouse/partner, for financial assistance;
d. any of the following: lending institutions; credit bureaus; the educational institution(s)
named in the Application; any employer; and any third party authorized to collect a
debt owed to Her Majesty the Queen in right of Alberta, in each case for any purpose
relating to the administration, enforcement or collection of the Alberta Student Loan;
e. federal government departments or agencies or the educational institution(s) named
in the Application to conduct research, statistical analysis, and evaluations related to
student financial assistance programs.
A D M IN IS T R A T IO N O F A L B E R T A S T U D E N T L O A N
8. The Minister designates the Student Aid Alberta Service Centre as the Minister’s agent
for the purposes of the administration of the Alberta Student Loan. The Student Aid
Alberta Service Centre may be contacted by phone at 1-855-606-2096 or by mail at
PO Box 4050, Mississauga Station A, Mississauga ON L5A 4M9.
T R A N S F E R A N D C O N V E R S IO N O F O U T S T A N D IN G G U A R A N T E E D O R R IS K - S H A R E D
L O A N S H E L D B Y A F IN A N C IN G IN S T IT U T IO N
9. The Student agrees to transfer to the Minister any outstanding guaranteed or risk-
shared loans the Student may have with any Financing Institution and authorizes
the Minister to act on the Student’s behalf in the transfer of these loans. The Student
understands and agrees that all such outstanding guaranteed or risk-shared loans
transferred to the Minister will be consolidated and subject to the Terms and Conditions
of this MSFAA-Alberta.
C O N V E R S IO N O F O U T S T A N D IN G G U A R A N T E E D O R R IS K - S H A R E D L O A N S H E L D
B Y T H E M IN IS T E R
10. If the Student has any outstanding guaranteed or risk-shared loans that had previously
been transferred to the Minister from a Financing Institution and these loans are
n o w h e ld b y th e M in is te r, th e S tu d e n t a g re e s t h a t a ll s u c h o u ts ta n d in g g u a ra n te e d o r
ris k -s h a re d lo a n s w ill b e c o n s o lid a te d a n d s u b je c t to th e T e rm s a n d C o n d itio n s o f th is
M S F A A -A lb e rta .
IN T E R E S T
11. The Student hereby acknowledges and agrees that:
a. the Alberta Student Loan shall bear interest from the Repayment Start Date, both
before and after default, before and after the maturity date and after judgment (with
interest on overdue interest at the same rate) at a floating rate equal to the Prime
Rate, accruing daily and calculated monthly;
b. if the Minister determines that there has been a Grant Overpayment after the
Repayment Start Date, the amount of the Grant Overpayment shall be converted
to an Alberta Student Loan and shall bear interest from the date the Grant
Overpayment is converted to an Alberta Student Loan.
c. changes in the Prime Rate shall cause an immediate adjustment to the interest
rate referred to in this section from the effective dates of such changes without the
necessity of notice to the Student from the Minister; and
d. the Student may request at any time during the repayment period, on a one-time
basis only, by written notice to the Minister, that interest be calculated at a fixed rate
not to exceed the Prime Rate in effect on the date that the Student’s written request
is received by the Minister plus 2%, instead of the floating interest rate set forth in
section 11(a) above; if the Student makes a request in accordance with this section
11(d), then the fixed rate of interest will apply to the Alberta Student Loan from the
date that the Student’s written request is received by the Minister, until such time as
the Alberta Student Loan, together with interest and any other amounts to be paid
by the Student to the Minister, are paid in full.
June 2015 Pai
Part E Additional Terms and Conditions - Page 2
REPAYM ENT 2 4 . T h e S tu d e n t a g re e s to in fo rm th e M in is te r o f a n y c h a n g e s to th e b a n k in fo rm a tio n
in w ritin g o r b y p h o n e .
12. T h e M in is te r w ill n o tify th e S tu d e n t, p rio r to th e R e p a y m e n t S ta r t D a te , o f th e fo llo w in g
in r e s p e c t o f th e A lb e r ta S tu d e n t L o a n : th e to ta l o u ts ta n d in g p rin c ip a l a m o u n t, th e
D E FAU LTS
re p a y m e n t p e rio d , th e m a tu rity d a te , th e L o a n P a y m e n t D a te a n d th e a m o u n t o f th e
in s ta llm e n t p a y m e n ts d u e o n e a c h L o a n P a y m e n t D a te . T h e m o n th ly in s ta llm e n t 2 5 . T h e o c c u rre n c e o f a n y o f th e fo llo w in g c ir c u m s ta n c e s o r e v e n ts c o n s titu te s a n e v e n t
a m o u n t c a lc u la te d w ill b e fix e d fo r th e re p a y m e n t p e rio d . In s ta llm e n t p a y m e n ts w ill o f d e fa u lt u n d e r th is M S F A A -A lb e rta :
b e a p p lie d firs t to a n y u n p a id c h a rg e s , s e c o n d ly to in te re s t (in c lu d in g o v e rd u e in te re s t)
a. th e S tu d e n t fa ils to p a y a n y a m o u n t o f p rin c ip a l o r in te re s t o w e d to th e M in is te r a n d
a n d th e n to th e p rin c ip a l a m o u n t o f th e A lb e rta S tu d e n t L o a n .
s u c h d e fa u lt c o n tin u e s fo r a p e rio d o f 2 m o n th s fro m its d u e d a te ;
13. If, a fte r th e R e p a y m e n t S ta rt D a te , th e M in is te r d e te r m in e s th a t th e re is a G ra n t
b. a n y r e p re s e n ta tio n o r w a rra n ty c o n ta in e d in th is M S F A A -A lb e rta o r in a n y fo rm ,
O v e rp a y m e n t a n d it is c o n v e rte d in to a n A lb e r ta S tu d e n t L o a n , th e M in is te r w ill,
c e r tific a te o r o th e r c o m m u n ic a tio n d e liv e re d p u rs u a n t to th is M S F A A -A lb e rta is
a s s o o n a s re a s o n a b ly p o s s ib le , n o tify th e S tu d e n t o f th e fo llo w in g in r e s p e c t o f th e
fo u n d to b e fa ls e o r in c o rr e c t o r la c k in g in m a te ria l fa c ts s o a s to m a k e it m a te ria lly
A lb e r ta S tu d e n t L o a n : th e to ta l o u ts ta n d in g p rin c ip a l a m o u n t, th e re p a y m e n t p e rio d ,
m is le a d in g , a s d e te rm in e d b y th e M in is te r a c tin g in th e M in is te r ’s s o le d is c re tio n ,
th e m a tu rity d a te , th e L o a n P a y m e n t D a te a n d th e a m o u n t o f th e in s ta llm e n t p a y m e n ts
a s a t th e tim e m a d e o r g iv e n ; o r
d u e o n e a c h L o a n P a y m e n t D a te . T h e m o n th ly in s ta llm e n t a m o u n t c a lc u la te d w ill b e
fix e d fo r th e re p a y m e n t p e rio d . In s ta llm e n t p a y m e n ts w ill b e a p p lie d fir s t to a n y u n p a id c. th e S tu d e n t b e c o m e s in s o lv e n t o r s u b je c t to a n y b a n k ru p tc y o r in s o lv e n c y
c h a rg e s , s e c o n d ly to in te re s t (in c lu d in g o v e rd u e in te re s t) a n d th e n to th e p rin c ip a l p ro c e e d in g s .
a m o u n t o f th e A lb e rta S tu d e n t L o a n .
R E M E D IE S O N D E F A U L T
14. If, a s a re s u lt o f a n y in c re a s e to th e P rim e R a te o r c o n v e rs io n o f a G ra n t O v e rp a y m e n t
to a n A lb e rta S tu d e n t L o a n a fte r th e R e p a y m e n t S ta rt D a te , th e M in is te r d e te rm in e s , 2 6 . U p o n th e o c c u rre n c e o f a n e v e n t o f d e fa u lt, th e M in is te r m a y :
in th e M in is te r ’s s o le d is c re tio n , th a t th e S tu d e n t’s m o n th ly lo a n p a y m e n ts w ill b e a. d e c la r e th e to ta l o u ts ta n d in g b a la n c e o f th e A lb e rta S tu d e n t L o a n , to g e th e r w ith
in s u ffic ie n t to r e p a y a ll o u ts ta n d in g p rin c ip a l b y th e m a tu rity d a te , th e M in is te r m a y a c c ru e d in te re s t a n d a ll o th e r o b lig a tio n s o f th e S tu d e n t u n d e r th is M S F A A -A lb e rta ,
a d v is e th e S tu d e n t o f a n in c re a s e in th e S tu d e n t’s m o n th ly lo a n p a y m e n t th a t is im m e d ia te ly d u e a n d p a y a b le a n d c a n c e l a n y p o rtio n o f A lb e r ta fin a n c ia l a s s is ta n c e
s u ffic ie n t, a s d e te r m in e d in th e M in is te r 's s o le d is c re tio n , to e n a b le s u c h re p a y m e n t. th a t h a s n o t y e t b e e n a d v a n c e d to th e S tu d e n t;
S h o u ld th is o c c u r, th e S tu d e n t a c k n o w le d g e s a n d a g re e s th a t h e o r s h e w ill b e o b lig e d
b. ta k e a n y a c tio n a g a in s t th e S tu d e n t p e rm itte d u n d e r th is M S F A A -A lb e rta o r a t la w
to p a y th e n e w m o n th ly p a y m e n t, in th e a m o u n t a n d a s o f th e d a te s p e c ifie d b y th e
o r in e q u ity a t s u c h tim e a n d in s u c h m a n n e r a s th e M in is te r m a y, in th e M in is te r ’s
M in is te r. A n y s u c h a d ju s tm e n t b y th e M in is te r to th e m o n th ly lo a n p a y m e n t m a y o c c u r
s o le a n d a b s o lu te d is c re tio n , d e e m a p p ro p ria te , a ll w ith o u t p re s e n ta tio n , d e m a n d ,
fro m tim e to tim e u n til s u c h tim e a s th e A lb e r ta S tu d e n t L o a n , t o g e th e r w ith in te re s t
p ro te s t, n o tic e , n o tic e o f d is h o n o u r o r a n y o th e r a c tio n w h a ts o e v e r, a ll o f w h ic h a re
a n d a n y o th e r a m o u n ts to b e p a id b y th e S tu d e n t to th e M in is te r, a r e p a id in fu ll.
h e re b y e x p r e s s ly w a iv e d b y th e S tu d e n t; a n d
15. In a d d itio n to th e o th e r re p a y m e n t p r o v is io n s c o n ta in e d in th is M S F A A -A lb e rta ,
c. d e n y th e S tu d e n t a n y fu rth e r fin a n c ia l a s s is ta n c e .
if th e S tu d e n t:
2 7 . A ll c o s ts a n d e x p e n s e s o f th e M in is te r in c u rre d in c o n n e c tio n w ith c o lle c tio n o r
a. c e a s e s to b e a F u ll T im e S tu d e n t d u rin g th e c o u rs e o f a s e m e s te r in a p ro g ra m o f stu d y:
e n fo r c e m e n t h e r e u n d e r (in c lu d in g le g a l c o s ts o n a s o lic ito r a n d o w n c lie n t b a s is ) s h a ll
i. th e M in is te r m a y, in th e M in is te r ’s s o le d is c re tio n , re q u ire th e S tu d e n t to b e fo r th e a c c o u n t o f th e S tu d e n t a n d s h a ll b e a r in te re s t fro m th e d a te o f d e m a n d .
im m e d ia te ly r e p a y a p o rtio n o r a ll o f th e A lb e rta S tu d e n t L o a n a n d c a n c e l a n y
p o rtio n o f th e A lb e rta fin a n c ia l a s s is ta n c e th a t h a s n o t y e t b e e n a d v a n c e d to th e A S S IG N M E N T O R S A L E O F S T U D E N T L O A N
S tu d e n t. A n y a d d itio n a l p o rtio n o f th e A lb e r ta S tu d e n t L o a n o u ts ta n d in g s h a ll be
2 8 . T h is M S F A A -A lb e rta m a y n o t b e a s s ig n e d b y th e S tu d e n t.
re p a id in a c c o rd a n c e w ith th e re p a y m e n t p ro v is io n s c o n ta in e d in th is M S F A A -
A lb e rta , a n d
AM ENDM ENTS
ii. th e S tu d e n t a c k n o w le d g e s a n d a g re e s th a t a n y re fu n d s o f t u itio n o r o th e r fe e s
2 9 . T h e M in is te r m a y a m e n d th is M S F A A -A lb e rta a t a n y tim e b y p o s tin g a d ire c tiv e
p a id b y o r o n b e h a lf o f th e S tu d e n t s h a ll b e d e e m e d to h a v e b e e n a s s ig n e d to
d e ta ilin g th e a m e n d m e n t o n th e M in is te r ’s w e b s ite p a g e s fo r s tu d e n t fin a n c ia l
th e M in is te r. T h e S tu d e n t fu rth e r a c k n o w le d g e s a n d a g re e s th a t a n y s u c h re fu n d
a s s is ta n c e a p p e a rin g o n th e S tu d e n t A id A lb e rta w e b s ite , s tu d e n ta id .a lb e rta .c a .
th e S tu d e n t r e c e iv e s s h a ll b e h e ld in tru s t fo r a n d b e im m e d ia te ly fo rw a rd e d to
th e M in is te r. T h e M in is te r s h a ll a p p ly th e p ro c e e d s o f a n y s u c h re fu n d , u p o n
E N T IR E A G R E E M E N T
re c e ip t th e re o f, a g a in s t th e o u ts ta n d in g A lb e rta S tu d e n t L o a n .
3 0 . S u b je c t to s e c tio n s 15b. a n d 2 9 o f t h is M S F A A -A lb e rta , th is M S F A A -A lb e rta c o n ta in s th e
b. is p e rm itte d th ro u g h a re p a y m e n t a s s is ta n c e p la n u n d e r th e A lb e rta S tu d e n t F in a n c e
e n tire a g re e m e n t o f th e p a rtie s c o n c e rn in g th e s u b je c t m a tte r o f th is M S F A A -A lb e rta a n d
A c ts to m a k e a n a ffo rd a b le p a y m e n t, o r if th e s tu d e n t re q u e s ts a re v is io n o f th e
n o o th e r u n d e rs ta n d in g s o r a g re e m e n ts , v e rb a l o r o th e rw is e , e x is t b e tw e e n th e p a rtie s .
re p a y m e n t te rm s fro m th e M in is te r a n d t h is r e q u e s t is a p p ro v e d , th e M in is te r s h a ll
a c k n o w le d g e th e S tu d e n t’s a ffo rd a b le p a y m e n t s c h e d u le o r re v is io n o f th e te rm s in
C H O IC E O F J U R IS D IC T IO N A N D L A W
w r itin g , a n d s u c h a c k n o w le d g e m e n t s h a ll fo rm p a rt o f th is A g re e m e n t.
3 1 . T h is M S F A A -A lb e rta s h a ll b e c o n s tru e d in a c c o r d a n c e w ith th e la w s in fo rc e in th e
16. S u b je c t to s e c tio n 18 a n d u n le s s o th e rw is e d u e e a r lie r u n d e r th e te rm s o f t h is M S F A A -
P r o v in c e o f A lb e r ta a n d th e C o u rts o f th e P r o v in c e o f A lb e r ta s h a ll h a v e e x c lu s iv e
A lb e rta , th e S tu d e n t s h a ll b e g in re p a y in g th e p rin c ip a l a m o u n t o f th e A lb e rta S tu d e n t
ju ris d ic tio n w ith re s p e c t to a ll m a tte r s re la tin g to o r a ris in g o u t o f th is M S F A A -A lb e rta .
L o a n , to g e th e r w ith in te re s t a n d a n y o th e r a m o u n ts p a y a b le b y th e S tu d e n t to th e
M in is te r, fro m th e R e p a y m e n t S ta rt D a te o n th e L o a n P a y m e n t D a te a n d s h a ll c o n tin u e
S E V E R A B IL IT Y
to p r o v id e p a y m e n t o n th e L o a n P a y m e n t D a te e a c h m o n th u n til th e A lb e rta S tu d e n t
L o a n , t o g e th e r w ith a c c ru e d in te re s t a n d a n y o th e r a m o u n ts p a y a b le b y th e S tu d e n t 3 2 . E a c h o f th e p ro v is io n s c o n ta in e d in th is M S F A A -A lb e rta is d is tin c t a n d s e v e ra b le a n d a
to th e M in is te r, a r e fu lly re p a id in a c c o rd a n c e w ith th e te rm s o f th is M S F A A -A lb e rta . d e c la r a tio n o f in v a lid ity , ille g a lity o r u n e n fo r c e a b ility o f a n y s u c h p ro v is io n , o r a n y p a rt
th e re o f, b y a c o u rt o f c o m p e te n t ju ris d ic tio n s h a ll n o t a ffe c t th e v a lid ity o r e n fo r c e a b ility
17. T h e S tu d e n t u n d e rs ta n d s a n d a g re e s th a t a ll fu n d s fo rw a r d e d in a c c o rd a n c e w ith
o f a n y o th e r p ro v is io n o f th is M S F A A -A lb e rta .
th is M S F A A -A lb e rta to th e S tu d e n t’s b a n k a c c o u n t in d ic a te d in th is M S F A A -A lb e rta ,
in c lu d in g a n y n e w b a n k a c c o u n ts in d ic a te d in th is M S F A A -A lb e rta in a c c o rd a n c e w ith
W A IV E R
s e c tio n 2 4 b e lo w , w ill b e d e e m e d to h a v e b e e n r e c e iv e d b y th e S tu d e n t a n d fo rm p a rt o f
th e A lb e rta S tu d e n t L o a n , u n le s s th e S tu d e n t p r o v id e s in fo rm a tio n to th e c o n tra ry 3 3 . N o d e la y o n th e p a rt o f th e M in is te r in e x e r c is in g a n y re m e d y , n o r a n y s in g le o r p a rtia l
to th e s a tis fa c tio n o f th e M in is te r. e x e rc is e o f a n y re m e d y a g a in s t th e S tu d e n t, n o r a n y w a iv e r b y th e M in is te r o f a n y o f
th e M in is te r ’s rig h ts a g a in s t th e S tu d e n t, s h a ll o p e ra te a s a w a iv e r o f a n y o f th e rig h ts
18. T h e S tu d e n t m a y r e p a y a t a n y tim e , w ith o u t n o tic e o r p e n a lty , a ll o r a n y p a rt o f th e
o r re s tric t o th e r o r fu rth e r e x e r c is e s o f s u c h re m e d y b y th e M in is te r, a ll r e m e d ie s b e in g
o u ts ta n d in g b a la n c e o f th e A lb e rta S tu d e n t L o a n , t o g e th e r w ith in te re s t a n d a n y
c u m u la tiv e a n d n o t e x c lu s iv e . A w a iv e r o f a n y b re a c h o f a te rm o r c o n d itio n o f th is
o th e r a m o u n ts p a y a b le b y th e S tu d e n t to th e M in is te r.
M S F A A -A lb e rta s h a ll n o t b in d th e p a rty g iv in g it u n le s s it is in w ritin g .

P R E - A U T H O R IZ E D D E B IT (P A D ) A U T H O R IZ A T IO N ( P E R S O N A L )
T IM E IS O F T H E E S S E N C E
19. T h e S tu d e n t a u th o riz e s th e M in is te r a n d th e fin a n c ia l in s titu tio n d e s ig n a te d in P a rt C
3 4 . T im e is o f th e e s s e n c e fo r th is M S F A A -A lb e rta .
( o r a n y o th e r fin a n c ia l in s titu tio n th e S tu d e n t m a y a u th o r iz e a t a n y tim e ) to b e g in
d e d u c tio n s a s p e r th e S tu d e n t’s in s tr u c tio n s fo r m o n th ly re g u la r re c u rrin g p a y m e n ts
a n d /o r o n e -tim e p a y m e n ts fro m tim e to tim e , to r e p a y th e lo a n . N O T IC E O F C O L L E C T IO N O F P E R S O N A L IN F O R M A T IO N

2 0 . T h e S tu d e n t c o n s e n ts to th e d is c lo s u re a n d e x c h a n g e o f th e S tu d e n t’s p e rs o n a l b a n k in g In n o v a tio n a n d A d v a n c e d E d u c a tio n is c o lle c tin g th is p e rs o n a l in fo rm a tio n u n d e r th e

in fo rm a tio n b y a n d b e tw e e n th e M in is te r a n d le n d in g in s titu tio n fo r th e p u rp o s e o f d ire c t
d e p o s it o f fu n d s .
2 1 . T h e M in is te r w ill c o n firm in w ritin g th e tim in g a n d a m o u n t o f th e p a y m e n ts w h e n th e
S tu d e n t is r e q u ire d to r e p a y th e lo a n .
2 2 . T h is a u th o r ity is to re m a in in e ffe c t u n til th e M in is te r h a s r e c e iv e d w r itte n n o tific a tio n
fro m th e S tu d e n t o f its c h a n g e o r te rm in a tio n . T h is n o tific a tio n m u s t b e r e c e iv e d a t le a s t
fiv e (5 ) b u s in e s s d a y s b e fo re th e n e x t d e b it is s c h e d u le d . T h e S tu d e n t m a y o b ta in a
s a m p le c a n c e lla tio n fo rm , o r o b ta in m o re in fo rm a tio n o n th e S tu d e n t’s rig h t to c a n c e l
a P A D A g re e m e n t a t th e S tu d e n t’s fin a n c ia l in s titu tio n o r b y v is itin g w w w .c d n p a y .c a .
2 3 . T h e S t u d e n t h a s c e r t a in r e c o u r s e r ig h t s if a n y d e b it d o e s n o t c o m p ly w i t h t h is
M S F A A - A lb e r t a . F o r e x a m p le , t h e S t u d e n t h a s t h e r ig h t t o r e c e iv e r e im b u r s e m e n t
f o r a n y d e b it t h a t is n o t a u t h o r iz e d o r is n o t c o n s i s t e n t w i t h t h is p r e - a u t h o r iz a t io n .
a u th o rity o f s e c tio n s 3 3 (a ) a n d (c ) o f th e F r e e d o m o f I n fo rm a tio n a n d P ro te c tio n o f
P r iv a c y A c t (A lb e rta ) to d e te r m in e a n d v e r ify y o u r e lig ib ility fo r fin a n c ia l a s s is ta n c e
a n d to a d m in is te r a n d e n fo rc e s tu d e n t fin a n c ia l a s s is ta n c e p ro g ra m s in a c c o rd a n c e
w ith th e S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb e rta ), th e C a n a d a S tu d e n t L o a n s A c t
a n d th e C a n a d a S tu d e n t F in a n c ia l A s s is ta n c e A c t, e a c h a s m a y b e a m e n d e d fro m
tim e to tim e . T h e u s e a n d d is c lo s u re o f y o u r p e rs o n a l in fo rm a tio n is m a n a g e d in
a c c o rd a n c e w ith th e F re e d o m o f I n fo rm a tio n a n d P r o te c tio n o f P r iv a c y A c t (A lb e rta ).
If y o u h a v e a n y q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n , c a ll th e S tu d e n t
A id A lb e rta S e rv ic e C e n tre to ll fre e a t 1 - 8 5 5 -6 0 6 -2 0 9 6 fro m a n y w h e r e in N o rth
A m e ric a . Y o u c a n a ls o m a il y o u r q u e s tio n s to th e S tu d e n t A id A lb e rta S e rv ic e C e n tre ,
E x e c u tiv e C u s to m e r A s s is ta n c e D e p a rtm e n t, P O B o x 4 0 5 0 , M is s is s a u g a S tn A ,
M is s is s a u g a O N L5A 4M 9.

Borrower Page 2 - Your Copy June 2015

1. T h is M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t -
A lb e rta (M S F A A -A lb e rta ) is b e tw e e n th e a p p lic a n t f o r
fin a n c ia l a s s is ta n c e , a s id e n tifie d in P a rt A ( “ S tu d e n t" )
a n d H e r M a je s ty th e Q u e e n in r ig h t o f A lb e rta a s
r e p re s e n te d b y th e M in is te r o f In n o v a tio n a n d A d v a n c e d
E d u c a tio n (“ M in is te r " o r “ In n o v a tio n a n d A d v a n c e d
E d u c a tio n ” ), m a d e p u rs u a n t to th e S tu d e n t F in a n c ia l
A s s is ta n c e A c t (A lb e rta ).
In c o n sid e ra tio n o f the M inister provid ing an A lb e rta S tuden t
Loa n u n d e r th is M S F A A -A lb erta, a n d b y s ig n in g P a rt D
b e lo w , th e S tuden t a grees to th e Term s and C o nditio ns
o f th is lo an a greem ent.
This M S FA A -A lberta is com prised of: Part A : Your Inform ation;
Part B: Term s an d C o n d itio n s; Part C: E le ctro n ic Funds
T ra n sfe r; P a rt D: Your A c k n o w le d g e m e n t an d S ignature;
Part E: A d d itio n a l Term s and C o nditio ns.
2. U ntil su ch tim e a s the A lb e rta S tuden t Loan, to g e th e r w ith
in te re st an d a n y o th e r a m o u n ts to be paid b y th e S tuden t to
the M in iste r are paid in full, th e S tuden t a grees:
a. th a t th is A lb e rta S tuden t Loan, to g e th e r w ith any and all
fu n d s o r o th e r fin a n cia l a ssista n ce receive d b y the S tuden t
fro m the M in iste r p u rsu a n t to th e A lb e rta S tuden t F inance
A cts shall be su b je ct to, g o ve rn e d b y an d form p a rt o f this
M S FA A -A lb erta, a s am e n d e d fro m tim e to tim e, e ntered
in to b e tw e en the S tuden t an d th e M inister.
to use the A lb e rta S tuden t Loan e xclu sive ly fo r the
p u rp o se s of o b ta in in g N e cessities;
th a t th e M in iste r m a y pay a p ortion o r all o f the A lb e rta
S tu d e n t Loa n d ire c tly to the e d u ca tio n a l in stitu tio n listed
on th e S tu d e n t’s A p p lica tio n fo r p a ym e n t o f the S tu d e n t's
tu itio n an d a n y m a n d a to ry fees;
to pro vid e no tice o f a n y ch a n g e s to th e S tu d e n t's nam e,
a d d re ss, m a rita l o r co m m o n la w partn e r status, finan cial
3.
circu m sta n ce s, a ca d e m ic sta tu s o r s tu d y period, a n y
cha n g e in the ad d re ss o r fin a n cia l circu m sta n ce s o f the
S tu d e n t's sp ou se/pa rtner, o r to any o th e r in form ation
con ta in e d in the A p p lica tio n , in a cco rd a n ce w ith the
in stru ctio n s re la tin g to ch a n g e s o f in fo rm a tio n fo u n d o n the
S tu d e n t A id A lb e rta w e bsite, stu d e n ta id .a lb e rta .ca :
to pro vid e all in fo rm a tio n requested by th e M in iste r w h ich,
in th e M in iste r's sole d iscre tio n , is required to ve rify a n y
sta te m e n ts m ade in this M S FA A -A lb erta;
to a bide b y all a p p lica b le p ro visio n s o f the A lb e rta S tuden t
F in a n ce A cts. If a n y o f the te rm s o f th is M S FA A -A lb erta
co n flict w ith a n y o f the A lb e rta S tu d e n t F inance A cts, then
th e p ro visio n s o f the a p p lica b le A lb e rta S tuden t F inance
A ct w ill app ly;
g. to re p a y the fu ll a m o u n t o f th e A lb e rta S tuden t Loan,
to g e th e r w ith in te re st and a n y o th e r a m o u n ts to be paid
b y the S tuden t to th e M inister, in a cco rd a n ce w ith the
p ro visio n s o f th is M S FA A -A lb e rta ; and
h. th a t this M S F A A -A lb e rta sh a ll re vo ke and re p la ce all
p re vio u s ag re e m e n ts th a t the S tuden t m ay h ave entered
in to w ith the M inister pursu a n t to any o f th e A lb e rta
S tuden t F in a n ce A cts.
T h e S tuden t d e cla re s that:
a. a ll in fo rm a tio n p rovid ed in th is M S F A A -A lb e rta and in all
o th e r fo rm s an d co m m u n ica tio n s s u b m itte d by th e Studen t
to th e M in iste r is tru e and co m p le te an d th e S tuden t
u n d e rsta n d s that th e in fo rm a tio n is su b je ct to review
an d a sse ssm e n t b y th e M inister in a cco rd a n ce w ith the
S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb erta); and
b. th e S tuden t has read, und e rsto o d , and a g re e s to be
b o u n d b y a ll the te rm s and co n d itio n s o f th is M SFA A-
A lb e rta in c lu d in g th o s e in P a rt E, w h ich form part o f th is
M S F A A -A lb erta, and a ckn o w le d g e s having reta in e d a
c o p y o f th is M S FA A -A lb erta.

T h is M S FA A -A lb erta d o e s not specify the actual am ount(s) that w ill be disbursed to you o r the am ount(s) you will be required to repay. The am ount(s) that will be disbursed to you under this M S FA A -A lb erta will
be dete rm in e d base d on nee ds assessm ent(s) o f yo u r A p plication(s) fo r finan cial assistan ce in a ccordan ce w ith federal and provincial legislation an d policies. You will be responsible und e r th is M SFA A-Alberta
for paying yo u r A lb e rta Studen t Loan. By sig ning Part D, you free ly p r o v id e y o u r c o n s e n t(s ), c e r tific a tio n ( s ) a n d r a tific a tio n (s ) and y o u a g re e t o a ll th e T e rm s a n d C o n d itio n s set out in the M SFAA-
Alberta. You und erstand that if you fail to sign this M SFA A -A lberta, you w ill not receive a n y finan cial assistance.

Signature Date (dd-mmm-yyyy)

F o r th e p u rp o s e o f v e rify in g th e d a ta p ro v id e d in th e A p p lic a tio n a n d th e M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta , I hereby conse nt to the release, b y C a nada R e venue A g ency to
an official o f Innovation and A d vanced Education, o f in form ation from m y in com e ta x returns and, if applicable, o th e r required ta xp a ye r in form ation a b o u t m e, w h e th e r supp lie d by m e o r b y a third party. The
in form ation w ill be relevant to and used solely fo r the purpose o f determ ining and verifying m y eligibility, entitlem ent fo r and the gen era l adm inistration and enforcem ent o f the student financial assistance program s
und e r the C a nada S tu d e n t L o a n s Act, th e C a n a d a S tu d e n t F in a n c ia l A s s ista n ce Act, the S tu d e n ts F in a n ce A c t (A lb erta), th e S tu d e n t L o a n A c t (A lb erta) an d the S tu d e n t F in a n c ia l A s s is ta n c e A c t (Alberta).
T h is a u th o riza tio n is v a lid fo r the ta xa tio n ye a r p rio r to th e ye a r o f sig n a tu re o f th is co nse nt, th e ye a r o f sig n a tu re o f th is co n se n t an d a n y o th e r s u b se q u e n t ta xa tio n ye a r fo r w h ich a ssista n ce is requested.

Signature Date (dd-mmm-yyyy)

Student Aid Alberta Service Centre CANADA POST STAMP

PO Box 4050 1 855 606-2096 (toll free from anywhere in North America)
Mississauga Stn A 1 855 306-2240 (TTY for the hearing impaired)
Mississauga ON 800 2 529-9242 (outside North America - add the appropriate
L5A 4M9 International Access Code)
Copy 1 - SAASC Copy June 2014
Pa1^age $6
1. T h is M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t -
A lb e rta (M S F A A -A lb e rta ) is b e tw e e n th e a p p lic a n t f o r
fin a n c ia l a s s is ta n c e , a s id e n tifie d in P a rt A ( “ S tu d e n t" )
a n d H e r M a je s ty th e Q u e e n in r ig h t o f A lb e rta a s
r e p re s e n te d b y th e M in is te r o f In n o v a tio n a n d A d v a n c e d
E d u c a tio n (“ M in is te r " o r “ In n o v a tio n a n d A d v a n c e d
E d u c a tio n ” ), m a d e p u rs u a n t to th e S tu d e n t F in a n c ia l
A s s is ta n c e A c t (A lb e rta ).
In c o n sid e ra tio n o f the M inister provid ing an A lb e rta S tuden t
Loa n u n d e r th is M S F A A -A lb erta, a n d b y s ig n in g P a rt D
b e lo w , th e S tuden t a grees to th e Term s and C o nditio ns
o f th is lo an a greem ent.
This M S FA A -A lberta is com prised of: Part A : Your Inform ation;
Part B: Term s an d C o n d itio n s; Part C: E le ctro n ic Funds
T ra n sfe r; P a rt D: Your A c k n o w le d g e m e n t an d S ignature;
Part E: A d d itio n a l Term s and C o nditio ns.
2. U ntil su ch tim e a s the A lb e rta S tuden t Loan, to g e th e r w ith
in te re st an d a n y o th e r a m o u n ts to be paid b y th e S tuden t to
the M in iste r are paid in full, th e S tuden t a grees:
a. th a t th is A lb e rta S tuden t Loan, to g e th e r w ith any and all
fu n d s o r o th e r fin a n cia l a ssista n ce receive d b y the S tuden t
fro m the M in iste r p u rsu a n t to th e A lb e rta S tuden t F inance
A cts shall be su b je ct to, g o ve rn e d b y an d form p a rt o f this
M S FA A -A lb erta, a s am e n d e d fro m tim e to tim e, e ntered
in to b e tw e en the S tuden t an d th e M inister.
to use the A lb e rta S tuden t Loan e xclu sive ly fo r the
p u rp o se s of o b ta in in g N e cessities;
th a t th e M in iste r m a y pay a p ortion o r all o f the A lb e rta
S tu d e n t Loa n d ire c tly to the e d u ca tio n a l in stitu tio n listed
on th e S tu d e n t’s A p p lica tio n fo r p a ym e n t o f the S tu d e n t's
tu itio n an d a n y m a n d a to ry fees;
to pro vid e no tice o f a n y ch a n g e s to th e S tu d e n t's nam e,
a d d re ss, m a rita l o r co m m o n la w partn e r status, finan cial
3.
circu m sta n ce s, a ca d e m ic sta tu s o r s tu d y period, a n y
cha n g e in the ad d re ss o r fin a n cia l circu m sta n ce s o f the
S tu d e n t's sp ou se/pa rtner, o r to any o th e r in form ation
con ta in e d in the A p p lica tio n , in a cco rd a n ce w ith the
in stru ctio n s re la tin g to ch a n g e s o f in fo rm a tio n fo u n d o n the
S tu d e n t A id A lb e rta w e bsite, stu d e n ta id .a lb e rta .ca :
to pro vid e all in fo rm a tio n requested by th e M in iste r w h ich,
in th e M in iste r's sole d iscre tio n , is required to ve rify a n y
sta te m e n ts m ade in this M S FA A -A lb erta;
to a bide b y all a p p lica b le p ro visio n s o f the A lb e rta S tuden t
F in a n ce A cts. If a n y o f the te rm s o f th is M S FA A -A lb erta
co n flict w ith a n y o f the A lb e rta S tu d e n t F inance A cts, then
th e p ro visio n s o f the a p p lica b le A lb e rta S tuden t F inance
A ct w ill app ly;
g. to re p a y the fu ll a m o u n t o f th e A lb e rta S tuden t Loan,
to g e th e r w ith in te re st and a n y o th e r a m o u n ts to be paid
b y the S tuden t to th e M inister, in a cco rd a n ce w ith the
p ro visio n s o f th is M S FA A -A lb e rta ; and
h. th a t this M S F A A -A lb e rta sh a ll re vo ke and re p la ce all
p re vio u s ag re e m e n ts th a t the S tuden t m ay h ave entered
in to w ith the M inister pursu a n t to any o f th e A lb e rta
S tuden t F in a n ce A cts.
T h e S tuden t d e cla re s that:
a. a ll in fo rm a tio n p rovid ed in th is M S F A A -A lb e rta and in all
o th e r fo rm s an d co m m u n ica tio n s s u b m itte d by th e Studen t
to th e M in iste r is tru e and co m p le te an d th e S tuden t
u n d e rsta n d s that th e in fo rm a tio n is su b je ct to review
an d a sse ssm e n t b y th e M inister in a cco rd a n ce w ith the
S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb erta); and
b. th e S tuden t has read, und e rsto o d , and a g re e s to be
b o u n d b y a ll the te rm s and co n d itio n s o f th is M SFA A-
A lb e rta in c lu d in g th o s e in P a rt E, w h ich form part o f th is
M S F A A -A lb erta, and a ckn o w le d g e s having reta in e d a
c o p y o f th is M S FA A -A lb erta.

T h is M S FA A -A lb erta d o e s not specify the actual am ount(s) that w ill be disbursed to you o r the am ount(s) you will be required to repay. The am ount(s) that will be disbursed to you under this M S FA A -A lb erta will
be dete rm in e d base d on nee ds assessm ent(s) o f yo u r A p plication(s) fo r finan cial assistan ce in a ccordan ce w ith federal and provincial legislation an d policies. You will be responsible und e r th is M SFA A-Alberta
for paying yo u r A lb e rta Studen t Loan. By sig ning Part D, you free ly p r o v id e y o u r c o n s e n t(s ), c e r tific a tio n ( s ) a n d r a tific a tio n (s ) and y o u a g re e t o a ll th e T e rm s a n d C o n d itio n s set out in the M SFAA-
Alberta. You und erstand that if you fail to sign this M SFA A -A lberta, you w ill not receive a n y finan cial assistance.

Signature Date (dd-mmm-yyyy)

F o r th e p u rp o s e o f v e rify in g th e d a ta p ro v id e d in th e A p p lic a tio n a n d th e M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta , I hereby conse nt to the release, b y C a nada R e venue A g ency to
an official o f Innovation and A d vanced Education, o f in form ation from m y in com e ta x returns and, if applicable, o th e r required ta xp a ye r in form ation a b o u t m e, w h e th e r supp lie d by m e o r b y a third party. The
in form ation w ill be relevant to and used solely fo r the purpose o f determ ining and verifying m y eligibility, entitlem ent fo r and the gen era l adm inistration and enforcem ent o f the student financial assistance program s
und e r the C a nada S tu d e n t L o a n s Act, th e C a n a d a S tu d e n t F in a n c ia l A s s ista n ce Act, the S tu d e n ts F in a n ce A c t (A lb erta), th e S tu d e n t L o a n A c t (A lb erta) an d the S tu d e n t F in a n c ia l A s s is ta n c e A c t (Alberta).
T h is a u th o riza tio n is v a lid fo r the ta xa tio n ye a r p rio r to th e ye a r o f sig n a tu re o f th is co nse nt, th e ye a r o f sig n a tu re o f th is co n se n t an d a n y o th e r s u b se q u e n t ta xa tio n ye a r fo r w h ich a ssista n ce is requested.

Signature Date (dd-mmm-yyyy)

Student Aid Alberta Service Centre CANADA POST STAMP

PO Box 4050 1 855 606-2096 (toll free from anywhere in North America)
Mississauga Stn A 1 855 306-2240 (TTY for the hearing impaired)
Mississauga ON 800 2 529-9242 (outside North America - add the appropriate
L5A 4M9 International Access Code)
Copy 2 - Your Copy June 2014
PaiW 3 ° j y
PART E ADDITIONAL TERMS AND CONDITIONS
D E F IN IT IO N S
4. In th is M S F A A -A lb e rta th e fo llo w in g te rm s s h a ll h a v e th e fo llo w in g m e a n in g s :
a. “A lb e rta S tu d e n t F in a n c e A c ts " m e a n s th e S tu d e n ts F in a n c e A c t (A lb e rta ), th e
S tu d e n t L o a n A c t (A lb e rta ) a n d th e S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb e rta ), a n d
a n y re g u la tio n s m a d e u n d e r th e s e A c ts , e a c h a s m a y b e a m e n d e d fro m tim e to tim e ;
b. “A lb e r ta S tu d e n t L o a n " c o lle c tiv e ly m e a n s a ll lo a n s m a d e to th e S tu d e n t fro m tim e
to tim e p u rs u a n t to a n y o f th e A lb e r ta S tu d e n t F in a n c e A c ts , in c lu d in g lo a n s m a d e
to th e S tu d e n t b y th e M in is te r, lo a n s m a d e to th e S tu d e n t b y a F in a n c in g In s titu tio n
a n d tra n s fe rre d to th e M in is te r, lo a n s m a d e w h ile th e S tu d e n t w a s a m in o r, a n d a ls o
in c lu d in g a n y G ra n t O v e rp a y m e n ts c o n v e rte d to a lo a n b y th e M in is te r u n d e r th e
A lb e r ta S tu d e n t F in a n c e A c ts ;
c. “ A p p lic a tio n ” m e a n s a ll a p p lic a tio n s , in th e fo rm p r e s c rib e d b y th e M in is te r,
s u b m itte d b y th e S tu d e n t to th e M in is te r fro m tim e to tim e p u rs u a n t to a n y o f th e
A lb e r ta S tu d e n t F in a n c e A c ts ;
d. “ C o m p le tio n o f S tu d ie s " m e a n s th e la s t d a y o f th e m o n th d u rin g w h ic h th e S tu d e n t
c e a s e s to b e a F u ll T im e S tu d e n t o r P a rt T im e S tu d e n t a n d a fte r w h ic h th e S tu d e n t
d o e s n o t b e c o m e a F u ll T im e S tu d e n t o r P a rt T im e S tu d e n t fo r a c o n tin u o u s p e rio d
o f s ix m o n th s a n d is n o t a P e rs o n o n P a re n ta l L e a v e ;
e. “ F in a n c in g In s titu tio n " m e a n s a fin a n c in g in s titu tio n a s d e fin e d in th e S tu d e n t
F in a n c ia l A s s is ta n c e A c t (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e ;
f. “ F u ll T im e S tu d e n t” m e a n s a S tu d e n t w h o is e n ro lle d in n o t le s s th a n 6 0 % , o r n o t
le s s th a n 4 0 % in th e c a s e o f a S tu d e n t w ith a d is a b ility , o f a fu ll-tim e p ro g ra m
o f s tu d y in th e s e m e s te r in q u e s tio n a t o n e o r m o re p o s t- s e c o n d a r y e d u c a tio n a l
in s titu tio n s , o r h a s th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l A s s is ta n c e
R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h d e fin itio n
p re v a ils in th e e v e n t o f a n y d is c re p a n c y ;
g. “ G ra n t O v e rp a y m e n t" m e a n s a g r a n t o v e r p a y m e n t a s d e fin e d in th e S tu d e n t
F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e ;
h. “ In te re s t F re e P e rio d " m e a n s th e c o n tin u o u s p e rio d c o m m e n c in g w h e n a p e rs o n
b e c a m e a F u ll T im e S tu d e n t o r a P a rt T im e S tu d e n t a n d c o n tin u in g u n til th e la st
d a y o f th e 6 th m o n th fo llo w in g th e m o n th in w h ic h th e p e rs o n c e a s e s to b e s u c h a
s tu d e n t, b u t tre a tin g a n y b r e a k o f 6 m o n th s or, in th e c a s e o f a P e rs o n o n P a re n ta l
L e a v e , 12 m o n th s o r le s s b e tw e e n th e t im e s th e p e rs o n c e a s e d to b e a fu ll-tim e o r
p a rt-tim e s tu d e n t a n d s u b s e q u e n tly b e c a m e a fu ll-tim e o r p a rt-tim e s tu d e n t a g a in a s
n o t b re a k in g th a t c o n tin u ity , o r h a s th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l
A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h
d e fin itio n p re v a ils in th e e v e n t o f a n y d is c re p a n c y ;
i. “ L o a n P a y m e n t D a te " m e a n s th e d a te o n w h ic h th e S tu d e n t w ill b e re q u ire d to p a y
a m o n th ly in s ta llm e n t a m o u n t to w a rd th e re p a y m e n t o f th e A lb e r ta S tu d e n t L o a n ;
j. “ M a s te r S tu d e n t F in a n c ia l A s s is ta n c e A g re e m e n t - A lb e rta " o r "M S F A A -A lb e rta "
m e a n s th is lo a n a g r e e m e n t a n d th e A p p lic a tio n ;
k. “ N e c e s s itie s " m e a n s th e n e c e s s a ry e x p e n s e s re q u ire d w h ile th e S tu d e n t is a
F u ll T im e S tu d e n t, s u c h a s tu itio n , b o o k s , fe e s , a n d b a s ic liv in g e x p e n s e s ;
l. “ P a rt T im e S tu d e n t" m e a n s a s tu d e n t w h o is e n ro lle d in le s s th a n 6 0 % , o r le s s
th a n 4 0 % in th e c a s e o f a s tu d e n t w ith a d is a b ility , o f a fu ll tim e p r o g ra m in th e
s e m e s te r in q u e s tio n a t o n e o r m o re p o s t s e c o n d a r y e d u c a tio n a l in s titu tio n s o r h a s
th e m e a n in g p ro v id e d fo r in th e S tu d e n t F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ),
a s m a y b e a m e n d e d fro m tim e to tim e , w h ic h d e fin itio n p r e v a ils in th e e v e n t o f a n y
d is c re p a n c y ;
m . “ P e rs o n o n P a re n ta l L e a v e " m e a n s : a ) a p a re n t ( w h e th e r b y b lo o d o r a d o p tio n ),
b ) a le g a l g u a rd ia n , o r c ) a n in d iv id u a l w h o b e c o m e s a s te p p a re n t u n d e r
c ir c u m s ta n c e s re c o g n iz e d b y th e M in is te r, w h o c e a s e s to b e a F u ll T im e S tu d e n t o r
a P a rt T im e S tu d e n t in o rd e r to g iv e b irth to , c a re fo r o r s u p p o rt a c h ild w h o is a n e w
a d d itio n to th e fa m ily b y re a s o n o f b irth , a d o p tio n , le g a l g u a rd ia n s h ip o r th o s e s te p
p a re n t c ir c u m s ta n c e s , a s th e c a s e m a y b e , o r h a s th e m e a n in g p ro v id e d fo r in th e
S tu d e n t F in a n c ia l A s s is ta n c e R e g u la tio n (A lb e rta ), a s m a y b e a m e n d e d fro m tim e
to tim e , w h ic h d e fin itio n p re v a ils in th e e v e n t o f a n y d is c re p a n c y ;
n. “ P rim e R a te " m e a n s th e v a ria b le re fe re n c e ra te o f in te r e s t a s c a lc u la te d m o n th ly
b y th e M in is te r b a s e d u p o n th e v a r ia b le re fe re n c e ra te o f in te re s t d e c la re d b y th e
C a n a d ia n Im p e ria l B a n k o f C o m m e rc e , o r its s u c c e s s o r, a s its ra te fo r C a n a d ia n
d o lla r c o n s u m e r d e m a n d lo a n s ;
o. “ R e p a y m e n t S ta rt D a te ” m e a n s th e d a te th a t th e S tu d e n t’s o b lig a tio n to r e p a y th e
A lb e rta S tu d e n t L o a n , to g e th e r w ith in te re s t, b e g in s , w h ic h is th e firs t d a y o f th e
s e v e n th m o n th fo llo w in g C o m p le tio n o f S tu d ie s ; a n d
p. “ S tu d e n t" m e a n s th e b o rro w e r u n d e r th is M S F A A -A lb e rta w h o h a s s u b m itte d a n
A p p lic a tio n a n d b e e n a p p ro v e d to r e c e iv e fin a n c ia l a s s is ta n c e fro m th e M in is te r.
TERM OF AG REEM EN T
5. T h is M S F A A -A lb e rta s e ts fo rth th e te rm s a n d c o n d itio n s a p p lic a b le to a ll A lb e r ta S tu d e n t
L o a n s m a d e to th e S tu d e n t fro m tim e to tim e , a n d s h a ll b e in e ffe c t u n til it is re p la c e d by
a s u b s e q u e n t a g re e m e n t.
O B L IG A T IO N T O IN F O R M
6. T h e S tu d e n t h e re b y a c k n o w le d g e s a n d a g re e s th a t:
a. th e m a k in g o f fa ls e o r m is le a d in g s ta te m e n ts in th is M S F A A -A lb e rta , fa ilu re to
d is c lo s e in fo rm a tio n o r fa ilin g to n o tify o f a n y c h a n g e s to in fo rm a tio n c o n ta in e d in
th is M S F A A -A lb e rta a s r e q u ire d b y th e p ro v is io n s o f th is M S F A A -A lb e rta , m a y re s u lt
in o n e o r m o re o f th e fo llo w in g :
i. th e S tu d e n t b e in g d e n ie d fin a n c ia l a s s is ta n c e ;
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ii. th e S tu d e n t b e in g re q u ire d to im m e d ia te ly r e p a y th e e n tire ty o f th e A lb e rta
S tu d e n t L o a n ;
iii. th e S tu d e n t b e in g s u b je c t to c r im in a l p ro s e c u tio n ;
b. th e S tu d e n t s h a ll n o t a p p ly fo r o r re c e iv e fin a n c ia l a s s is ta n c e fro m a n o th e r p ro v in c e
o r te rr ito r y fo r a n y p e rio d o f tim e d u rin g w h ic h th e S tu d e n t is r e c e iv in g a n A lb e rta
S tu d e n t L o a n fro m th e M in is te r; a n d
c. a ll fu n d s r e c e iv e d b y th e S tu d e n t p u rs u a n t to th e A lb e rta S tu d e n t F in a n c e A c ts to
w h ic h th e S tu d e n t is n o t e n title d u n d e r th is M S F A A -A lb e rta , in c lu d in g th o s e re s u ltin g
fro m a n y a d m in is tra tiv e e rro rs , s h a ll b e c o m e a d e b t d u e to H e r M a je s ty th e Q u e e n
in r ig h t o f A lb e rta a n d m a y b e re c o v e re d fro m th e S tu d e n t b y a n a c tio n in d e b t.
D IS C L O S U R E O F IN F O R M A T IO N
7. U n til s u c h tim e a s th e A lb e rta S tu d e n t L o a n , to g e th e r w ith in te re s t a n d a n y o th e r a m o u n ts
to b e p a id b y th e S tu d e n t to th e M in iste r, is p a id in fu ll, th e S tu d e n t a c k n o w le d g e s th e
a u th o rity o f, a n d w h e re a c o n s e n t is re q u ire d , h e re b y irre v o c a b ly a u th o riz e s , th e M in is te r
to d is c lo s e a n d e x c h a n g e th e S tu d e n t’s p e rs o n a l in fo rm a tio n w ith :
a. th e G o v e rn m e n t o f C a n a d a , th e N a tio n a l S tu d e n t L o a n s S e rv ic e C e n tre , a n y
p ro v in c ia l, te rrito ria l o r m u n ic ip a l g o v e rn m e n t d e p a rtm e n t o r a g e n c y , a n y le n d in g
in s titu tio n w h e re th e S tu d e n t m a y h a v e a s tu d e n t lo a n , a n y e d u c a tio n a l in s titu tio n ,
a n y la n d lo rd , c re d it b u re a u o r e m p lo y e r fo r a n y p u rp o s e re la te d to th e v e r ific a tio n o f
in fo rm a tio n p r o v id e d b y th e S tu d e n t a n d fo r a d m in is tra tio n a n d e n fo r c e m e n t o f th e
C anada S tu d e n t Loa n s Act, th e C anada S tu d e nt F in an cia l A s sista n ce A c t a n d th e
A lb e rta S tu d e n t F in a n c e A c ts , e a c h a s m a y b e a m e n d e d fro m tim e to tim e ;
b. E m p lo y m e n t a n d S o c ia l D e v e lo p m e n t C a n a d a th ro u g h th e S o c ia l In s u ra n c e
R e g is try to v e r ify th e S tu d e n t’s S o c ia l In s u ra n c e N u m b e r, n a m e , d a te o f b irth ,
a n d g e n d e r s o le ly to c o n firm id e n tific a tio n fo r th e p u rp o s e o f fin a n c ia l a s s is ta n c e ;
c. A lb e r ta H u m a n S e rv ic e s to o p e ra te a n d a d m in is te r s tu d e n t fin a n c ia l a s s is ta n c e
p ro g ra m s , in c lu d in g d e te r m in in g th e S tu d e n t’s e lig ib ility , a n d th e e lig ib ility o f th e
S tu d e n t’s s p o u s e /p a rtn e r, fo r fin a n c ia l a s s is ta n c e ;
d. a n y o f th e fo llo w in g : le n d in g in s titu tio n s ; c re d it b u re a u s ; th e e d u c a tio n a l in s titu tio n (s )
n a m e d in th e A p p lic a tio n ; a n y e m p lo y e r; a n d a n y th ird p a rty a u th o riz e d to c o lle c t a
d e b t o w e d to H e r M a je s ty th e Q u e e n in rig h t o f A lb e rta , in e a c h c a s e fo r a n y p u rp o s e
re la tin g to th e a d m in is tra tio n , e n fo rc e m e n t o r c o lle c tio n o f th e A lb e rta S tu d e n t L o a n ;
e. fe d e ra l g o v e rn m e n t d e p a rtm e n ts o r a g e n c ie s o r th e e d u c a tio n a l in s titu tio n (s ) n a m e d
in th e A p p lic a tio n to c o n d u c t re s e a rc h , s ta tis tic a l a n a ly s is , a n d e v a lu a tio n s re la te d to
s tu d e n t fin a n c ia l a s s is ta n c e p ro g ra m s .
A D M IN IS T R A T IO N O F A L B E R T A S T U D E N T L O A N
8. T h e M in is te r d e s ig n a te s th e S tu d e n t A id A lb e rta S e rv ic e C e n tre a s th e M in is te r 's a g e n t
fo r th e p u r p o s e s o f th e a d m in is tra tio n o f th e A lb e rta S tu d e n t L o a n . T h e S tu d e n t A id
A lb e r ta S e rv ic e C e n tre m a y b e c o n ta c te d b y p h o n e a t 1 -8 5 5 - 6 0 6 - 2 0 9 6 o r b y m a il a t
P O B o x 4 0 5 0 , M is s is s a u g a S ta tio n A , M is s is s a u g a O N L5A 4M 9.
T R A N S F E R A N D C O N V E R S IO N O F O U T S T A N D IN G G U A R A N T E E D O R R IS K -S H A R E D
L O A N S H E L D B Y A F IN A N C IN G IN S T IT U T IO N
9. T h e S tu d e n t a g re e s to tra n s fe r to th e M in is te r a n y o u ts ta n d in g g u a ra n te e d o r ris k -
s h a re d lo a n s th e S tu d e n t m a y h a v e w ith a n y F in a n c in g In s titu tio n a n d a u th o riz e s
th e M in is te r to a c t o n th e S tu d e n t’s b e h a lf in th e t ra n s fe r o f th e s e lo a n s . T h e S tu d e n t
u n d e rs ta n d s a n d a g re e s th a t a ll s u c h o u ts ta n d in g g u a ra n te e d o r ris k -s h a re d lo a n s
tra n s fe rre d to th e M in is te r w ill b e c o n s o lid a te d a n d s u b je c t to th e T e rm s a n d C o n d itio n s
o f th is M S F A A -A lb e rta .
C O N V E R S IO N O F O U T S T A N D IN G G U A R A N T E E D O R R I S K -S H A R E D L O A N S H E L D
B Y T H E M IN IS T E R
10. If th e S tu d e n t h a s a n y o u ts ta n d in g g u a ra n te e d o r r is k -s h a re d lo a n s th a t h a d p re v io u s ly
b e e n tra n s fe rre d to th e M in is te r fro m a F in a n c in g In s titu tio n a n d th e s e lo a n s a re
n o w h e ld b y th e M in is te r, th e S tu d e n t a g re e s th a t a ll s u c h o u ts ta n d in g g u a ra n te e d o r
r is k -s h a re d lo a n s w ill b e c o n s o lid a te d a n d s u b je c t to th e T e rm s a n d C o n d itio n s o f th is
M S F A A -A lb e rta .
IN T E R E S T
11. T h e S tu d e n t h e re b y a c k n o w le d g e s a n d a g re e s th a t:
a. th e A lb e r ta S tu d e n t L o a n s h a ll b e a r in te re s t fro m th e R e p a y m e n t S ta rt D a te , b o th
b e fo re a n d a fte r d e fa u lt, b e fo re a n d a fte r th e m a tu rity d a te a n d a fte r ju d g m e n t (w ith
in te re s t o n o v e rd u e in te re s t a t th e s a m e ra te ) a t a flo a tin g ra te e q u a l to th e P rim e
R a te , a c c ru in g d a ily a n d c a lc u la te d m o n th ly ;
b. if th e M in is te r d e te r m in e s th a t th e re h a s b e e n a G ra n t O v e rp a y m e n t a fte r th e
R e p a y m e n t S ta rt D a te , th e a m o u n t o f th e G ra n t O v e rp a y m e n t s h a ll b e c o n v e rte d
to a n A lb e rta S tu d e n t L o a n a n d s h a ll b e a r in te re s t fro m th e d a te th e G ra n t
O v e rp a y m e n t is c o n v e rte d to a n A lb e r ta S tu d e n t L o a n .
c. c h a n g e s in th e P rim e R a te s h a ll c a u s e a n im m e d ia te a d ju s tm e n t to th e in te re s t
ra te re fe rre d to in th is s e c tio n fro m th e e ffe c tiv e d a te s o f s u c h c h a n g e s w ith o u t th e
n e c e s s ity o f n o tic e to th e S tu d e n t fro m th e M in is te r; a n d
d. th e S tu d e n t m a y re q u e s t a t a n y tim e d u rin g th e r e p a y m e n t p e rio d , o n a o n e -tim e
b a s is o n ly , b y w r itte n n o tic e to th e M in is te r, t h a t in te re s t b e c a lc u la te d a t a fix e d ra te
n o t to e x c e e d th e P rim e R a te in e ffe c t o n th e d a te th a t th e S tu d e n t’s w r itte n r e q u e s t
is re c e iv e d b y th e M in is te r p lu s 2 % , in s te a d o f th e flo a tin g in te re s t r a te s e t fo rth in
s e c tio n 1 1(a) a b o v e ; if th e S tu d e n t m a k e s a r e q u e s t in a c c o rd a n c e w ith th is s e c tio n
1 1(d), th e n th e fix e d ra te o f in te re s t w ill a p p ly to th e A lb e rta S tu d e n t L o a n fro m th e
d a te th a t th e S tu d e n t’s w ritte n re q u e s t is r e c e iv e d b y th e M in is te r, u n til s u c h tim e a s
th e A lb e r ta S tu d e n t L o a n , to g e th e r w ith in te re s t a n d a n y o th e r a m o u n ts to b e p a id
b y th e S tu d e n t to th e M in is te r, a r e p a id in fu ll.
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PART E ADDITIONAL TERMS AND CONDITIONS - PAGE 2
REPAYM ENT
12. T h e M in is te r w ill n o tify th e S tu d e n t, p r io r t o th e R e p a y m e n t S ta rt D a te , o f th e fo llo w in g
in r e s p e c t o f th e A lb e rta S tu d e n t L o a n : th e to ta l o u ts ta n d in g p rin c ip a l a m o u n t, th e
r e p a y m e n t p e rio d , th e m a tu rity d a te , th e L o a n P a y m e n t D a te a n d th e a m o u n t o f th e
in s ta llm e n t p a y m e n ts d u e o n e a c h L o a n P a y m e n t D a te . T h e m o n th ly in s ta llm e n t
a m o u n t c a lc u la te d w ill b e fix e d fo r th e re p a y m e n t p e rio d . In s ta llm e n t p a y m e n ts w ill
b e a p p lie d fir s t to a n y u n p a id c h a rg e s , s e c o n d ly to in te re s t (in c lu d in g o v e r d u e in te re s t)
a n d th e n to th e p rin c ip a l a m o u n t o f t h e A lb e r ta S tu d e n t L o a n .
13. If, a fte r th e R e p a y m e n t S ta rt D a te , th e M in is te r d e te r m in e s t h a t th e r e is a G ra n t
O v e rp a y m e n t a n d it is c o n v e rte d in to a n A lb e rta S tu d e n t L o a n , th e M in is te r w ill,
a s s o o n a s re a s o n a b ly p o s s ib le , n o tify th e S tu d e n t o f th e fo llo w in g in re s p e c t o f th e
A lb e r ta S tu d e n t L o a n : th e to ta l o u ts ta n d in g p rin c ip a l a m o u n t, th e re p a y m e n t p e rio d ,
th e m a tu rity d a te , th e L o a n P a y m e n t D a te a n d th e a m o u n t o f th e in s ta llm e n t p a y m e n ts
d u e o n e a c h L o a n P a y m e n t D a te . T h e m o n th ly in s ta llm e n t a m o u n t c a lc u la te d w ill b e
fix e d fo r th e re p a y m e n t p e rio d . In s ta llm e n t p a y m e n ts w ill b e a p p lie d firs t to a n y u n p a id
c h a rg e s , s e c o n d ly to in te re s t (in c lu d in g o v e rd u e in te re s t) a n d th e n to th e p rin c ip a l
a m o u n t o f th e A lb e rta S tu d e n t L o a n .
14. If, a s a re s u lt o f a n y in c re a s e to th e P rim e R a te o r c o n v e rs io n o f a G ra n t O v e rp a y m e n t
to a n A lb e r ta S tu d e n t L o a n a fte r th e R e p a y m e n t S ta rt D a te , th e M in is te r d e te rm in e s ,
in th e M in is te r 's s o le d is c re tio n , t h a t th e S tu d e n t’s m o n th ly lo a n p a y m e n ts w ill b e
in s u ffic ie n t to r e p a y a ll o u ts ta n d in g p rin c ip a l b y th e m a tu rity d a te , th e M in is te r m a y
a d v is e th e S tu d e n t o f a n in c re a s e in th e S tu d e n t's m o n th ly lo a n p a y m e n t th a t is
s u ffic ie n t, a s d e te rm in e d in th e M in is te r ’s s o le d is c re tio n , to e n a b le s u c h re p a y m e n t.
S h o u ld t h is o c c u r, th e S tu d e n t a c k n o w le d g e s a n d a g re e s th a t h e o r s h e w ill b e o b lig e d
to p a y th e n e w m o n th ly p a y m e n t, in th e a m o u n t a n d a s o f th e d a te s p e c ifie d b y th e
M in is te r. A n y s u c h a d ju s tm e n t b y th e M in is te r to th e m o n th ly lo a n p a y m e n t m a y o c c u r
fro m tim e to tim e u n til s u c h tim e a s th e A lb e r ta S tu d e n t L o a n , t o g e th e r w ith in te re s t
a n d a n y o th e r a m o u n ts to b e p a id b y th e S tu d e n t t o th e M in is te r, a r e p a id in fu ll.
15. In a d d itio n to th e o th e r re p a y m e n t p ro v is io n s c o n ta in e d in th is M S F A A -A lb e rta , if th e
S tu d e n t c e a s e s to b e a F u ll T im e S tu d e n t d u r in g th e c o u r s e o f a s e m e s te r in a p ro g ra m
o f s tu d y :
a. th e M in is te r m a y , in th e M in is te r ’s s o le d is c re tio n , re q u ire th e S tu d e n t to im m e d ia te ly
r e p a y a p o rtio n o r a ll o f th e A lb e r ta S tu d e n t L o a n a n d c a n c e l a n y p o rtio n o f th e
A lb e rta fin a n c ia l a s s is ta n c e th a t h a s n o t y e t b e e n a d v a n c e d to th e S tu d e n t.
A n y a d d itio n a l p o rtio n o f th e A lb e rta S tu d e n t L o a n o u ts ta n d in g s h a ll b e re p a id in
a c c o rd a n c e w ith th e re p a y m e n t p ro v is io n s c o n ta in e d in t h is M S F A A -A lb e rta , a n d
b. th e S tu d e n t a c k n o w le d g e s a n d a g r e e s th a t a n y re fu n d s o f tu itio n o r o th e r fe e s
p a id b y o r o n b e h a lf o f th e S tu d e n t s h a ll b e d e e m e d to h a v e b e e n a s s ig n e d to
th e M in is te r. T h e S tu d e n t fu rth e r a c k n o w le d g e s a n d a g re e s th a t a n y s u c h re fu n d
th e S tu d e n t r e c e iv e s s h a ll b e h e ld in tru s t fo r a n d b e im m e d ia te ly fo rw a r d e d to
th e M in is te r. T h e M in is te r s h a ll a p p ly th e p ro c e e d s o f a n y s u c h re fu n d , u p o n
re c e ip t th e re o f, a g a in s t th e o u ts ta n d in g A lb e r ta S tu d e n t L o a n .
16. S u b je c t to s e c tio n 1 8 a n d u n le s s o th e rw is e d u e e a r lie r u n d e r th e te rm s o f th is M S F A A -
A lb e rta , th e S tu d e n t s h a ll b e g in re p a y in g th e p rin c ip a l a m o u n t o f th e A lb e r ta S tu d e n t
L o a n , to g e th e r w ith in te re s t a n d a n y o th e r a m o u n ts p a y a b le b y th e S tu d e n t to th e
M in is te r, fro m th e R e p a y m e n t S ta rt D a te o n th e L o a n P a y m e n t D a te a n d s h a ll c o n tin u e
to p r o v id e p a y m e n t o n th e L o a n P a y m e n t D a te e a c h m o n th u n til th e A lb e r ta S tu d e n t
L o a n , t o g e th e r w ith a c c ru e d in te re s t a n d a n y o th e r a m o u n ts p a y a b le b y th e S tu d e n t
to th e M in is te r, a re fu lly re p a id in a c c o rd a n c e w ith th e te rm s o f th is M S F A A -A lb e rla .
17. T h e S tu d e n t u n d e rs ta n d s a n d a g r e e s t h a t a ll fu n d s fo rw a r d e d in a c c o r d a n c e w ith
th is M S F A A -A lb e rta to th e S tu d e n t's b a n k a c c o u n t in d ic a te d in th is M S F A A -A lb e rta ,
in c lu d in g a n y n e w b a n k a c c o u n ts in d ic a te d in th is M S F A A - A lb e rla in a c c o rd a n c e w ith
S e c tio n 2 4 b e lo w , w ill b e d e e m e d to h a v e b e e n r e c e iv e d b y th e S tu d e n t a n d fo rm p a rt
o f t h e A lb e rta S tu d e n t L o a n , u n le s s th e S tu d e n t p ro v id e s in fo rm a tio n to th e c o n tra ry
to th e s a tis fa c tio n o f th e M in is te r.
18. T h e S tu d e n t m a y r e p a y a t a n y tim e , w ith o u t n o tic e o r p e n a lty , a ll o r a n y p a rt o f th e
o u ts ta n d in g b a la n c e o f th e A lb e rta S tu d e n t L o a n , t o g e th e r w ith in te re s t a n d a n y
o th e r a m o u n ts p a y a b le b y th e S tu d e n t t o t h e M in is te r.
P R E -A U T H O R IZ E D D E B IT (P A D ) A U T H O R IZ A T IO N (P E R S O N A L )
19. T h e S tu d e n t a u th o r iz e s th e M in is te r a n d th e fin a n c ia l in s titu tio n d e s ig n a te d in P a rt C
( o r a n y o th e r fin a n c ia l in s titu tio n th e S tu d e n t m a y a u th o r iz e a t a n y tim e ) to b e g in
d e d u c tio n s a s p e r th e S tu d e n t’s in s tru c tio n s fo r m o n th ly re g u la r re c u rrin g p a y m e n ts
a n d /o r o n e -tim e p a y m e n ts fro m tim e to tim e , to r e p a y th e lo a n .
2 0 . T h e S tu d e n t c o n s e n ts t o th e d is c lo s u re a n d e x c h a n g e o f th e S tu d e n t’s p e rs o n a l b a n k in g
in fo rm a tio n b y a n d b e tw e e n th e M in is te r a n d le n d in g in s titu tio n fo r th e p u r p o s e o f d ire c t
d e p o s it o f f u n d s .
2 1 . T h e M in is te r w ill c o n fir m in w r itin g th e tim in g a n d a m o u n t o f th e p a y m e n ts w h e n th e
S tu d e n t is r e q u ire d to r e p a y th e lo a n .
2 2 . T h is a u th o r ity is t o re m a in in e ffe c t u n til th e M in is te r h a s r e c e iv e d w r itte n n o tific a tio n
fro m th e S tu d e n t o f its c h a n g e o r te rm in a tio n . T h is n o tific a tio n m u s t b e r e c e iv e d a t le a s t
fiv e (5 ) b u s in e s s d a y s b e fo re th e n e x t d e b it is s c h e d u le d . T h e S tu d e n t m a y o b ta in a
s a m p le c a n c e lla tio n fo rm , o r o b ta in m o re in fo rm a tio n o n th e S tu d e n t's rig h t to c a n c e l
a P A D A g re e m e n t a t th e S tu d e n t's fin a n c ia l in s titu tio n o r b y v is itin g w w w .c d n p a y .c a .
2 3 . T h e S t u d e n t h a s c e r t a in r e c o u r s e r ig h t s i f a n y d e b it d o e s n o t c o m p ly w i t h t h is
M S F A A - A lb e r t a . F o r e x a m p le , t h e S t u d e n t h a s t h e r ig h t t o r e c e iv e r e im b u r s e m e n t
f o r a n y d e b it t h a t is n o t a u t h o r iz e d o r is n o t c o n s i s t e n t w i t h t h is p r e - a u t h o r iz a t io n .
2 4 . T h e S tu d e n t a g r e e s fo in fo rm th e M in is te r o f a n y c h a n g e s to th e b a n k in fo rm a tio n
in w r itin g o r b y p h o n e .
Borrower Page 2 - Your Copy
D E FAU LTS
2 5 . T h e o c c u r r e n c e o f a n y o f th e fo llo w in g c ir c u m s ta n c e s o r e v e n ts c o n s titu te s a n e v e n t
o f d e fa u lt u n d e r t h is M S F A A -A lb e rta :
a. th e S tu d e n t fa ils to p a y a n y a m o u n t o f p rin c ip a l o r in te re s t o w e d to th e M in is te r a n d
s u c h d e fa u lt c o n tin u e s fo r a p e rio d o f 2 m o n th s fro m its d u e d a te :
b. a n y r e p re s e n ta tio n o r w a rr a n ty c o n ta in e d in th is M S F A A -A lb e rta o r in a n y fo rm ,
c e r tific a te o r o th e r c o m m u n ic a tio n d e liv e r e d p u rs u a n t to th is M S F A A -A lb e rta is
fo u n d to b e fa ls e o r in c o rre c t o r la c k in g in m a te ria l fa c ts s o a s to m a k e it m a te ria lly
m is le a d in g , a s d e te r m in e d b y th e M in is te r a c tin g in th e M in is te r 's s o le d is c re tio n ,
a s a t th e tim e m a d e o r g iv e n ; o r
c. th e S tu d e n t b e c o m e s in s o lv e n t o r s u b je c t to a n y b a n k ru p tc y o r in s o lv e n c y
p ro c e e d in g s .
R E M E D IE S O N D E F A U L T
2 6 . U p o n th e o c c u rre n c e o f a n e v e n t o f d e fa u lt, th e M in is te r m a y :
a. d e c la re th e to ta l o u ts ta n d in g b a la n c e o f th e A lb e rta S tu d e n t L o a n , t o g e th e r w ith
a c c ru e d in te re s t a n d a ll o th e r o b lig a tio n s o f th e S tu d e n t u n d e r t h is M S F A A -A lb e rta ,
im m e d ia te ly d u e a n d p a y a b le a n d c a n c e l a n y p o rtio n o f A lb e rta fin a n c ia l a s s is ta n c e
th a t h a s n o t y e t b e e n a d v a n c e d to th e S tu d e n t;
b. ta k e a n y a c tio n a g a in s t th e S tu d e n t p e rm itte d u n d e r th is M S F A A -A lb e rta o r a t la w
o r in e q u ity a t s u c h tim e a n d in s u c h m a n n e r a s th e M in is te r m a y , in th e M in is te r 's
s o le a n d a b s o lu te d is c re tio n , d e e m a p p ro p ria te , a ll w ith o u t p re s e n ta tio n , d e m a n d ,
p ro te s t, n o tic e , n o tic e o f d is h o n o u r o r a n y o th e r a c tio n w h a ts o e v e r, a ll o f w h ic h a re
h e re b y e x p r e s s ly w a iv e d b y t h e S tu d e n t; a n d
c. d e n y th e S tu d e n t a n y fu rth e r fin a n c ia l a s s is ta n c e .
2 7 . A ll c o s ts a n d e x p e n s e s o f th e M in is te r in c u rre d in c o n n e c tio n w ith c o lle c tio n o r
e n fo r c e m e n t h e r e u n d e r (in c lu d in g le g a l c o s ts o n a s o lic ito r a n d o w n c lie n t b a s is ) s h a ll
b e fo r th e a c c o u n t o f th e S tu d e n t a n d s h a ll b e a r in te r e s t fro m th e d a te o f d e m a n d .
A S S IG N M E N T O R S A L E O F S T U D E N T L O A N
2 8 . T h is M S F A A -A lb e rta m a y n o t b e a s s ig n e d b y th e S tu d e n t.
AM ENDM ENTS
2 9 . T h e M in is te r m a y a m e n d t h is M S F A A -A lb e rta a t a n y tim e b y p o s tin g a d ire c tiv e
d e ta ilin g th e a m e n d m e n t o n th e M in is te r’s w e b s ite p a g e s fo r s tu d e n t fin a n c ia l
a s s is ta n c e a p p e a rin g o n th e S tu d e n t A id A lb e r ta w e b s ite , s tu d e n ta id .a lb e rta .c a .
E N T IR E A G R E E M E N T
3 0 . S u b je c t to s e c tio n 2 9 o f th is M S F A A -A lb e rta , th is M S F A A -A lb e rta c o n ta in s th e e n tire
a g r e e m e n t o f th e p a rtie s c o n c e rn in g th e s u b je c t m a tte r o f th is M S F A A -A lb e rta a n d n o
o th e r u n d e rs ta n d in g s o r a g re e m e n ts , v e rb a l o r o th e rw is e , e x is t b e tw e e n th e p a rtie s .
C H O IC E O F J U R IS D IC T IO N A N D L A W
3 1 . T h is M S F A A -A lb e rta s h a ll b e c o n s tru e d in a c c o rd a n c e w ith th e la w s in fo rc e in th e
P ro v in c e o f A lb e rta a n d th e C o u rts o f t h e P ro v in c e o f A lb e rta s h a ll h a v e e x c lu s iv e
ju ris d ic tio n w ith re s p e c t to a ll m a tte r s re la tin g to o r a ris in g o u t o f th is M S F A A -A lb e rla .
S E V E R A B IL IT Y
3 2 . E a c h o f th e p ro v is io n s c o n ta in e d in th is M S F A A -A lb e rta is d is tin c t a n d s e v e r a b le a n d a
d e c la r a tio n o f in v a lid ity , ille g a lity o r u n e n fo r c e a b ility o f a n y s u c h p ro v is io n , o r a n y p a rt
th e re o f, b y a c o u rt o f c o m p e te n t ju ris d ic tio n s h a ll n o t a ffe c t th e v a lid ity o r e n fo r c e a b ility
o f a n y o th e r p ro v is io n o f th is M S F A A -A lb e rta .
W A IV E R
3 3 . N o d e la y o n th e p a rt o f th e M in is te r in e x e rc is in g a n y re m e d y , n o r a n y s in g le o r p a rtia l
e x e rc is e o f a n y re m e d y a g a in s t th e S tu d e n t, n o r a n y w a iv e r b y th e M in is te r o f a n y o f
th e M in is te r ’s rig h ts a g a in s t th e S tu d e n t, s h a ll o p e ra te a s a w a iv e r o f a n y o f th e rig h ts
o r re s tric t o th e r o r fu rth e r e x e r c is e s o f s u c h re m e d y b y th e M in is te r, a ll r e m e d ie s b e in g
c u m u la tiv e a n d n o t e x c lu s iv e . A w a iv e r o f a n y b re a c h o f a te rm o r c o n d itio n o f th is
M S F A A -A lb e rta s h a ll n o t b in d th e p a rty g iv in g it u n le s s it is in w ritin g .
T IM E IS O F T H E E S S E N C E
3 4 . T im e is o f th e e s s e n c e o f th is M S F A A -A lb e rta .
N O T IC E O F C O L L E C T IO N O F P E R S O N A L IN F O R M A T IO N
In n o v a tio n a n d A d v a n c e d E d u c a tio n is c o lle c tin g th is p e rs o n a l in fo rm a tio n u n d e r th e
a u th o rity o f s e c tio n s 3 3 (a ) a n d (c ) o f th e F re e d o m o f In fo r m a tio n a n d P ro te c tio n o f
P r iv a c y A c t (A lb e rta ) to d e te r m in e a n d v e r ify y o u r e lig ib ility fo r f in a n c ia l a s s is ta n c e
a n d to a d m in is te r a n d e n fo rc e s tu d e n t fin a n c ia l a s s is ta n c e p r o g r a m s in a c c o rd a n c e
w ith th e S tu d e n t F in a n c ia l A s s is ta n c e A c t (A lb e rta ), th e C a n a d a S tu d e n t L o a n s A c t
a n d th e C a n a d a S tu d e n t F in a n c ia l A s s is ta n c e A c t, e a c h a s m a y b e a m e n d e d fro m
tim e to tim e . T h e u s e a n d d is c lo s u r e o f y o u r p e rs o n a l in fo rm a tio n is m a n a g e d in
a c c o rd a n c e w ith th e F re e d o m o f I n fo rm a tio n a n d P ro te c tio n o f P r iv a c y A c t (A lb e rta ).
If y o u h a v e a n y q u e s tio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n , c a ll th e S tu d e n t
A id A lb e r ta S e rv ic e C e n tre to ll fre e a t 1 -8 5 5 - 6 0 6 - 2 0 9 6 fro m a n y w h e r e in N o rth
A m e ric a . Y o u c a n a ls o m a il y o u r q u e s tio n s to th e S tu d e n t A id A lb e rta S e rv ic e C e n tre ,
E x e c u tiv e C u s to m e r A s s is ta n c e D e p a rtm e n t, P O B o x 4 0 5 0 , M is s is s a u g a S tn A ,
M is s is s a u g a O N L 5 A 4 M 9 .
June 2014 Pat
CA LCU LA TED NEED R EQ U ESTED NEED
60 % C L :

Funding Type Orig Award Add’l Award Total Award

TOTAL

CSL

ASL

MG

GRANT 1

GRANT 2

GRANT 3

GRANT 4

ASCLK# ID#
I I I I I I I
S F /C O C N o v 2 0 1 4

Page 365
 Need Assessment Report 20___-20
Marital Status Number of Dependants Assess Date Social Insurance Number

Costs Federal Provincial

Tuition
Fees
Books/Supplies
Computer Cost
Living Allowance H
Ax mos
Living Allowance H
Ax mos
Child Care ($75/mo/child)
$ x Months
Travel
Med/Den/Opt
Exceptional Expenses
TOTAL COSTS

R esources
Parental/Spouse Contribution
Pre-Study Contribution
Part-time Earnings
Other Resources
Other Resources
Assets/RRSP
Scholarships

TOTAL RESOURCES
CALCULATED NEED
60% CL:

Funding Type Orig Award Add’l Award Total Award

TOTAL SN Message
CSL

ASL
MG
GRANT 1
GRANT 2
GRANT 3
GRANT 4
GRANT
GRANT

ASCLK# App ID

_J___ I___ I___ I___ I___ I - I ,-l

SF/COC
 Adult High School Equivalency Scholarship - Nomination Form

The Adult High School Equivalency Scholarship recognizes and rewards academic achievement in the attainment of high school
equivalency and provides an incentive for mature students to continue their education at the post-secondary level.

Award Amount - $500

Eligibility Criteria

A nominee must:

a. be a Canadian citizen or a Permanent Resident,

b. be an Alberta resident, and to to be considered an Alberta resident one of the following conditions must apply:
• one parent must currently be residing in Alberta, or
• Alberta is the last place the student has lived for twelve (12) consecutive months before being a full-time student, or
• is married to an Alberta resident before the start of the qualifying year of study.
c. have been out of high school for a minimum of three (3) years before starting a high school equivalency program,
d. have been enrolled full-time in a high school equivalency program in Alberta of at least one year in length,
e. achieved an academic average of 80% or a GPA of 3.5 or greater in their high school equivalency program, and
f. be enrolled or intending to enroll full-time in a post-secondary program after completing a high school equivalency
program.

Selection Procedures

Recipients are nominated by the Student Awards Office at the Alberta educational institution where they completed their high school
equivalency program.

Return completed application to the Student Awards Office at your educational institution.

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Nomination Deadline: Contact the Student Awards Office

Information on other awards is available on: studentaid.alberta.ca/scholarships

Page 368
 Adult High School Equivalency Scholarship - Nomination Form

Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom
of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award
under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this
information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

Alberta Student Number (go to cducation.gov.ab.ca to find your ASN or to obtain one) Social Insurance Number (required for processing)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender ( c i r c l e o n e ) Birthdate Email

M F day m o n th year
___ l __ 1 1
_____ _____ _____ ______ 1______1_____

CITIZENSHIP (check one)

□ CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: A t ta c h a p h o to c o p y o f p e r m a n e n t re s id e n t c a r d . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Does one parent currently reside in Alberta? N Have you lived in Alberta all your life? N
IF Y O U H A V E A N S W E R E D “ N O ” T O B O T H Q U E S T IO N S , If no, since
P L E A S E IN C L U D E A L E T T E R E X P L A IN IN G T H E T IM E Y O U JLnth l vci" i
S P E N T IN A L B E R T A A S A N O N F U L L -T IM E S T U D E N T .

PROPOSED POST-SECONDARY STUDIES

Name of Institution

Institution City Start Date for Program Program

m o n th | year
I I I I I

Office Use Only

[oo
Loo
loo

91
CM

<3)
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

E
MO YR SFB AUTHORIZATION AWARD KEY APP KEY

Revised: O c f . 2 0 1 ^
 Declaration of Nominee
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing one
semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information 1 have provided to Student Aid Alberta and for the
use in research and statistical analysis in program evaluation.

1 UNDERSTAND AND AGREE THAT:

if 1 receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Nominee Today’s Date (in ink)

To be Completed by the Nominating Institution

NOMINEE’S SECONDARY EDUCATION

Name o f High School (before starting upgrading):________________________

Date Last Attended High School: ____________ Highest Grade Completed:

NOMINEE’S UPGRADING PROGRAM:

Nominated by: ___________________________________________________________

Name of Institution

Average in upgrading program:

Date nominee completed upgrading:

Nominee meets the eligibility requirements: Yes Q No

Name of Institution Official Signature of Official

Date: ________________________________

Page 370
 Charles S. Noble Junior Football Scholarship - Nomination Form

The Charles S. Noble Junior Football Scholarship honours the agricultural entrepreneur, innovator and farm implement
manufacturer who became one of Alberta’s biggest and best grain farmers.

The Charles S. Noble Junior Football Scholarship rewards the athletic and academic excellence of junior football players at
universities, colleges and technical institutes in Alberta.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the three Alberta Junior Football Teams.

Award Value - $1,000

Eligibility

Applicant must:
a. be a Canadian citizen or Permanent Resident and be an Alberta resident,
b. be a playing member on an Alberta Junior Football team,
c. be enrolled as a full-time student at a post-secondary institution in Alberta and maintaining an academic standing of at least
65% or a GPA of 2.0 on a GPA scale of 4.0, and
d. be recommended by the Scholarship Committee of the Alberta Junior Football teams.

Scholarships will be paid in two installments of $500 each on December 1 and April 1. Recipients must continue to meet the
eligibility criteria in order to receive the second installment.

Selection Procedures

Nominations from each Junior Football Team in Alberta (Edmonton Wildcats, Edmonton Huskies, and the Calgary Colts) are
forwarded to the Scholarship Committee. The Committee will select a maximum of ten nominees from each team in any given year
and forward the recommendations to Alberta Scholarship Programs for final approval.

Faxed applications not accepted.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Application Deadline: October 1

Page 372
 CHARLES S. NOBLE JUNIOR FOOTBALL SCHOLARSHIP - NOMINATION FORM

Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom
of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award
under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this
information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

U s e the L earn er R e g istry at e d u c a tio n .g o v .a b .c a . to fin d y o u r A lb erta S tu d en t N u m b er or to h a v e o n e a s sig n e d .

Alberta Student Number (required for p rocessin g) Social Insurance Number (required for p rocessin g)

Last Name (curren t fu ll le g a l n a m e ) P le a s e u s e up per an d lo w e r c a se . First Name ant One Initial (cu rren t fu ll le g a l n a m e)

Mailing Address (In c lu d e A p t, or B o x N u m b er) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M F m<j»nth
ty ___ i yT i

CITIZENSHIP (check one)

CANADIAN CITIZEN or FH PERMANENT RESIDENT (Landed Immigrant)
N o t e : A t ta c h a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N

Have you livec in Alberta all your life? If y o u r p a r e n t s d o n o t c u r r e n t l y r e s id e in A l b e r t a AND y o u h a v e n o tl iv e d in

Y N Since m o n th year
A l b e r ia a l l y o u r l if e , p l e a s e in c l u d e a l e t t e r e x p l a in in g t h e t im e s p e n t in

__ _L_______I___J___ I___ A l b e r t a a s a n o n f u l l - t im e s t u d e n t .

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Office Use Only

89 8 0 3 © 2
GRANT TOTAL AWD INSTIT PGM MO YR l\ O YR ORG ADD
D is b u r s e m e n t
D ec 1 - 500
19 E
Apr 1 - 500
SPORT MO YR ASP AUTHORIZATION AWARD KEY APP KEY

R e v is e d : S e p t 2 0 1 5
Page 373
 Declaration of Nominee

I have read and understand the instructions, and declare that:

a. All information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing one
semester of studies.

I understand and agree that:

a. Personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. Personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. My personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta,
and for the use in research and statistical analysis in program evaluation.

I understand and agree that:

If I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Applicant Today’s Date (in ink)

This Section to be Completed by the Nominating Team

Name of Team: _____________________________________________________

Name of Official:

Position:

Signature of Official:

Page 374
 Charles S. Noble Junior Hockey Scholarship - Nomination Form

The Charles S. Noble Junior Hockey Scholarship honours the agricultural entrepreneur, innovator and farm implement manufacturer
who became one of Alberta’s biggest and best grain farmers.

The Charles S. Noble Junior Hockey Scholarship rewards the athletic and academic excellence of Junior Hockey players and
provides an incentive and means for these players to continue with their post-secondary education.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the Friends of Alberta Junior Hockey Society.

Award Value -1 0 Awards of $2,000

Eligibility Criteria

Applicant must:
a. be a Canadian citizen or Permanent Resident and be an Alberta resident,
b. be a participant, or have been a participant, in at least one full season of hockey with a Hockey Alberta registered hockey
team and have played during the last year or are currently playing,
c. be enrolled as a full-time student at a post-secondary institution in Alberta and and maintaining an academic standing of at
least 65% or greater or a grade point average of 2.0 on a 4.0 scale, and
d. be recommended by the Scholarship Committee of the Friends of Alberta Junior Hockey Society.

Nomination Selection Procedures

Nominations from each Junior Hockey Team in Alberta are forwarded to the Scholarship Committee. Each nomination must include
a current transcript and attachments outlining the applicant’s extra curricular activities and future goals.

The Committee will select recipients based on academic standing, community involvement and hockey achievements.

Faxed applications are not accepted.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed
to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their
fullest potential.

Application Deadline: December 1

Page 376
 Charles S. Noble Junior Hockey Scholarship - Nomination Form

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an
award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information:

Use the Learner Registry at e d u c a tio n .g o v .a b .ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender ( c i r c l e o n e ) Birthdate Email Address

M m o n th
f ay ____ T i yr i

CITIZENSHIP (check one)

1 CANADIAN CITIZEN or I PERMANENT RESIDENT (Landed Immigrant)
---------- ----------- N o t e : A tta c h a p h o to c o p y o f p e r m a n e n t r e s id e n t c a r d . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N

Have y< a lived in Alberta all your life? If y o u r p a r e n t s d o n o t c u r r e n t l y r e s id e in A l b e r t a A N D y o u h a v e n o t l iv e d in

Y N Since A l b e r t a a l l y o u r l if e , p l e a s e in c l u d e a l e t t e r e x p l a in in g t h e t im e s p e n t ' in

A l b e r t a a s a n o n f u l l - t im e s t u d e n t .

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Institution City Entry Date for Program Program

n jo n th
___i y<j a r i__

POST-SECONDARY STUDENT I.D. NUMBER

Office Use Only

89 8 0 5 © 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u r s e m e n t

21 E
SPORT MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: Nov 2015

Page 377
 Declaration of Nominee

I have read and understand the instructions, and declare that:

a. All information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

1 understand and agree that:

a. My personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. My personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. My personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta, and for use
in research and statistical analysis in program evaluation and program promotion.

I understand and agree that::

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Nominee (in ink) Today’s Date (in ink)

Section to be Completed by the Nominating Team

Name of Team: ___

Name of Official: __

Position: _________

Signature of Official:

Nom ination Form

Page 378
 Hockey Record of Nominee:
Note: To be considered, players must have played in the Junior Hockey League last year or be currently playing,

a. List Junior teams played for and years played:

b. Statistical Record (past and current years)

c. Awards or distinctions received (scholastic/sports)

Provide the following information as an attachment to the nomination form:

1. A short summary outlining the player’s extra curricular activities within the community during the past few years.
The statement should be typed and no more than one page in length, and

2. A brief outline of the player’s future plans/goals. This should also be typed and no longer than one page.

For more information on other awards administered by Student Aid Alberta contact:

Student Aid Alberta Service Centre: 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Page 379
Charles S. Noble
Junior Hockey
Scholarship

Page
 Charles S. Noble Junior Hockey Scholarship - Nomination Form

The Charles S. Noble Junior Hockey Scholarship honours the agricultural entrepreneur, innovator and farm implement manufacturer
who became one of Alberta’s biggest and best grain farmers.

The Charles S. Noble Junior Hockey Scholarship rewards the athletic and academic excellence of Junior Hockey players and
provides an incentive and means for these players to continue with their post-secondary education.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the Friends of Alberta Junior Hockey Society.

Award Value -1 0 Awards of $2,000

Eligibility Criteria

Applicant must:
a. be a Canadian citizen or Permanent Resident and be an Alberta resident,
b. be a participant, or have been a participant, in at least one full season of hockey with a Hockey Alberta registered hockey
team and have played during the last year or are currently playing,
c. be enrolled as a full-time student at a post-secondary institution in Alberta and and maintaining an academic standing of at
least 65% or greater or a grade point average of 2.0 on a 4.0 scale, and
d. be recommended by the Scholarship Committee of the Friends of Alberta Junior Hockey Society.

Nomination Selection Procedures

Nominations from each Junior Hockey Team in Alberta are forwarded to the Scholarship Committee. Each nomination must include
a current transcript and attachments outlining the applicant’s extra curricular activities and future goals.

The Committee will select recipients based on academic standing, community involvement and hockey achievements.

Faxed applications are not accepted.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed
to stimulate the pursuit o f excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their
fullest potential.

Application Deadline: December 1

Page 381
 Charles S. Noble Junior Hockey Scholarship - Nomination Form

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an
award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information:

Use the Learner Registry at e d u c a tio n .g o v .a b .ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender ( c i r c l e o n e ) Birthdate Email Address

M month
f ay ___T i yr i

CITIZENSHIP (check one)

1 CANADIAN CITIZEN or I PERMANENT RESIDENT (Landed Immigrant)
---------- ----------- N o t e : A tta c h a p h o to c o p y o f p e r m a n e n t r e s id e n t c a r d . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school?
Y N

Have y< a lived in Alberta all your life? Ifyo u r p a r e n t s d o n o t c u r r e n t l y r e s id e in A l b e r t a A N D y o u h a v e n o t l iv e d in

Y N Since A l b e r t a a l l y o u r l if e , p l e a s e in c l u d e a l e t t e r e x p l a in in g t h e t im e s p e n t ' in

A l b e r t a a s a n o n f u l l - t im e s t u d e n t .

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Institution City Entry Date for Program Program

njonth
___i y<jar i__

POST-SECONDARY STUDENT I.D. NUMBER

Office Use Only

89 8 0 5 © 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u r s e m e n t

21 E
SPORT MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: Nov 2015

Page 382
 Declaration of Nominee

I have read and understand the instructions, and declare that:

a. All information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

1 understand and agree that:

a. My personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. My personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. My personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta, and for use
in research and statistical analysis in program evaluation and program promotion.

I understand and agree that::

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Nominee (in ink) Today’s Date (in ink)

Section to be Completed by the Nominating Team

Name of Team: ___

Name of Official: __

Position: _________

Signature of Official:

Nomination Form

Page 383
 Hockey Record of Nominee:
Note: To be considered, players must have played in the Junior Hockey League last year or be currently playing,

a. List Junior teams played for and years played:

b. Statistical Record (past and current years)

c. Awards or distinctions received (scholastic/sports)

Provide the following information as an attachment to the nomination form:

1. A short summary outlining the player’s extra curricular activities within the community during the past few years.
The statement should be typed and no more than one page in length, and

2. A brief outline of the player’s future plans/goals. This should also be typed and no longer than one page.

For more information on other awards administered by Student Aid Alberta contact:

Student Aid Alberta Service Centre: 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Page 384
 Jason Lang Scholarship - Nomination Form
This scholarship was established in memory of Jason Lang, a 17 year old high school student who was killed in a school
shooting. The scholarship recognizes and rewards Alberta post-secodary students for their academic achievements and
encourages them to continue in their undergraduate or professional program of study.

Award Value - $1,000

Eligibility Criteria

To be eligible an applicant must:

• be a Canadian Citizen or Permanent Resident (visa students are not eligible),
• be an Alberta resident and to be considered an Alberta resident one of the following conditions must apply:
- one parent must currently be residing in Alberta, or
- Alberta is the last place you have lived for twelve (12) consecutive months before being a full-time post-secondary
student, or
- you are married to an Alberta resident before the start of your qualifying year of study.
• be enrolled in an undergraduate or professional program such as Law, Medicine, Pharmacy, Dentistry or Veterinary
Medicine at a participating post-secondary educational institution in Alberta,
• be enrolled in a program of study which is a minimum of two years in length or greater, i.e. a program must offer a
minimum of four academic terms or 64 weeks of academic instruction, excluding work term and/or co-op, and
• have completed at least 80% of a full course load and achieved a minimum Grade Point Average of 3.2 on a 4.0 scale
in the previous academic year during the fall and winter semesters.

Students who are nominated for a scholarship and transfer to a non-participating post-secondary institution are eligible to
receive payment of the scholarship. Students must be continuing their post-secondary studies in the 2015-2016 academic year
and must provide confirmation of their full-time enrollment to Student Aid Alberta.

Students are not eligible for a Jason Lang Scholarship if they:

• are enrolled in a one year certificate program,
• interrupt their post-secondary studies for more than one semester in the next academic year,
• are recipients of a Louise McKinney Scholarship for the same period of study, or
• have received the lifetime maximum of three Jason Lang Scholarships.

Selection Procedure
Students who meet the eligibility criteria are nominated by the Student Awards Office at the Alberta post-secondary institution
where they completed their qualifying year of studies.

Payment of the Award

To receive payment of the award, nominees must be:
• continuing their post-secondary studies in the next academic year, either the fall or winter semesters, and
• enrolled full-time, i.e. taking a minimum of a 60% of a full course load for a minimum of one semester.

Students who are nominated in the fall semester receive their cheque in mid-December and students who are nominated
in the winter semester receive their cheque at the end of March.

Submit your completed application form to the Student Awards Office

at your educational institution.

Page 386
 Jason lang Scholarship - Nomination Form
Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an
award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

Alberta Student Number (go to www.education.gov.ab.ca to find your ASN or to obtain one) Social Insurance Number

CITIZENSHIP (check one)

| CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
N o t e : In c lu d e a p h o to c o p y o f p e r m a n e n t r e s id e n t c a rd o r im m ig r a t io n lo n g f o r m . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY*
*Do your parents currently live in Alberta? *Havei/ou lived in Alberta all your life? If ‘NO’ since
Y N Y N
__ I__ __ I___!___I__
m o n th year

EDUCATION INFORMATION
Previous Academic Year: 2014-2015 Name oi Ptogtam

Name of Educational Institution Academic Year Start Date Academic Year End Date

m o n th year m o n th year

Student ID
Length of Program: | | Years

* I f your parents do not currently reside in Alberta AND you have not lived in Alberta all your life,
please include a letter explaining the time spent in Alberta as a non full-time student.

Office Use Only

Revised: Jan. 2016

Page 387
Education Information (continued)
Current Academic Year: 2015-2016

Name of Educational Institution Academic Year Start Date Academic Year End Date

month year month year

Length of Program | | Years

Name of Program

Student ID

Note: A student may receive no more than the lifetime maximum of three Jason Lang Scholarships.

Declaration of Nominee
I have read and understand the instructions, and declare that:
a. All information provided is true and complete and I understand it is subject to verification;
b. I will be a full-time post-secondary student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies
before completing one semester of studies.

1 understand and agree that:

a. My personal information pertaining to my post-secondary academic record may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of
determining my eligibility for a scholarship;
b. My personal information pertaining to my post-secondary academic enrolment status may be
released and exchanged by and between Student Aid Alberta and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. My personal information may be released and exchanged by and between Student Aid Alberta and
any provincial government departments, boards or institutions to verify the information I provided
to Student Aid Alberta and for the use in research and statistical analysis in program evaluation.
1 understand and agree that:
if I receive a scholarship, my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

For in fo rm a tio n on o th e r awards, visit studentaid.alberta.ca/scholarships

Page 388
 Jimmie Condon Athletic Scholarship - Nomination Form
The Jimmie Condon Athletic Scholarship was named in honour of Jimmie Condon, philanthropist and long-time supporter and
promoter of amateur sports in Calgary. The scholarship rewards athletic and academic excellence at universities, colleges and
technical institutes in Alberta.

The Jimmie Condon Athletic Scholarship is funded by the Government of Alberta as part of Alberta Innovation and Advanced
Education Achievement Scholarship Program.

Award Value - Up to $1,800

Eligibility Criteria
To be eligible, a student athlete must be:
• a member of a designated university, college or technical institute team, or
• a member of a Provincial Disabled Athletic Team recognized by the Alberta Athlete Development Program.

In addition, a nominee must:

• be a Canadian Citizen or permanent resident (visa students are not eligible),
• be an Alberta resident as defined by the Jimmie Condon program regulations - a student will be considered an Alberta resident
if a parent or parents currently reside in Alberta, or Alberta is the last place the student has lived for twelve (12) consecutive
months before being a full-time student, or the student was enrolled full-time at a designated post-secondary institution for two
consecutive semesters during a regular academic year, or is married to an Alberta resident before the start of the qualifying year
of study,
• enrolled full-time defined as taking a minimum of a 60% course load or greater in the qualifying semester, and
• maintain a practice and training program acceptable to their coach.

Returning students: must have maintained a Grade Point Average) of 2.0 on a 4.0 grade point scale on their previous term of full­
time study, (excluding spring and summer courses),
New students who have had a break in their studies do not need to meet the above GPA requirement.

Students in an upgrading or college preparation program may qualify after completing one semester of upgrading providing they
meet the academic and athletic requirements. Apprenticeship students are also eligible for this scholarship.

The scholarship is paid in two installments of $900 each - the first in December and the second in April. Recipients must continue to
meet the eligibility criteria in order to receive the second disbursement.

Members of designated teams are nominated by the Athletics Department at the post-secondary institution they are currently attending.
Contact the Athletics Department for further information.

Nomination Procedure
Return the completed nomination form to the team coach.
For information on this award and other scholarships administered by Student Aid Alberta contact:

Student Aid Alberta Service Centre: 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Page 390
 Jimmie Condon Athletic Scholarship - Nomination Form

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an
award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection
of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information for Nominee:

Use the Learner Registry at: education.gov.ab.ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname:
Province Postal Code Area Code Telephone Number Email:

CITIZENSHIP (check one) ALBERTA RESIDENCY (answer both)

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta?
PERMANENT RESIDENT (Landed Immigrant) Y N Have you lived in Alberta for the last 12
Include a photocopy o f permanent resident card.
N o te : consecutive months as a non full-time
Visa students are not eligible. student before attending school full-time?
Sender (circle one) Birthdate (Day/Month/Year) OR Have you attended a post-secondary
institution full-time in Alberta for the last
M F ___ I___ I ___ I___ I___ I___
two consecutive semesters?
I f y o u h a v e a n sw e r e d ‘N O ' to B O T H q u e s t io n s , p le a s e a tt a c h a le t t e r
POST-SECONDARY EDUCATION e x p la in in g y o u r t im e s p e n t in A lb e r t a . j

Institution currently attending: Name of program:

Name of Sport Student D Number:

Are you applying as a Provincial disabled athlete? N

Office Use Only

27
C M

888
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D is b u rs e m e n t
D e cem be r - 900
A p ril - 900
SPORT MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: Jan. 2016

Page 391
 Nominee’s Educational Record
P ost-S e co n d a ry E d u ca tio n : List last two (2) post-secondary schools attended to date including current institution.
PERIOD OF STUDY INSTITUTION ENROLLMENT STATUS
F r o m (m m /y y ) T o (m m /y y ) N a m e o f I n s titu tio n Program Y ear o f P rogram L e n g th o f P r o g r a m

Declaration of Nominee
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. All information provided is true and complete and I understand it is subject to verification,
b. I will be a full-time student at the institution named for the period stated, and
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies,
or drop to part-time studies.

I UNDERSTAND AND AGREE THAT:

a. Personal information pertaining to my post-secondary academic record and enrolment status may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of determining
my eligibility for a scholarship, and
b. Personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

If 1 receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Student Aid Alberta.

Signature of Nominee (in ink) Today’s Date (in ink)

To be completed by the Nominating Institution:

Term: Winter
Name of Nominating Institution

Name of Coach Signature of Coach (in ink)

Page 392
 Languages in Teacher Education Scholarship - Nomination Form
This scholarship program is designed to reward Alberta post-secondary students enrolled in a recognized Alberta teacher
preparation program taking courses that will allow them to teach languages other than English, including FNMI
languages in Alberta schools. This scholarship was created by an endowment from the Government o f Alberta to the
Alberta Heritage Scholarship Fund to build provincial capacity in the area of language education.

Teachers interested in summer professional development in the area of another language should contact Student Aid
Alberta regarding the Language Teacher Bursary Program.

Award Amount 2,500

Eligibility Criteria
A candidate must be:

• a Canadian Citizen or Permanent resident - visa students are not eligible;

• an Alberta resident - to be considered an Alberta resident one o f the following conditions must apply:
*a parent or parent(s) is currently residing in Alberta, or
*Alberta is the last place the nominee has lived for 12 consecutive months before being a full-time student, or
*is married to an Alberta resident before the start o f the qualifying year o f study, and
• enrolled full-time in the final two years o f a recognized Alberta teacher preparation program offered by an Alberta
Faculty o f Education.

Nomination Procedures
Recipients are nominated by the Faculty o f Education at each eligible post-secondary institutions. Institutions will select
students who meet the eligibility criteria and who are completing an education program that will allow them to be a
language teacher in Alberta schools after they graduate.

Institutions:
• must balance the nominations across the range o f language programs, including FNMI languages, and
• may use academic performance to select recipients.

To help meet the needs o f the increasing FNMI (First Nations, Metis, Inuit) student participation, institutions will give
consideration to students eligible to teach aboriginal languages.

Note: A student may only receive this scholarship once.

Eligible Institutions & Allocation of Awards

University of Alberta 4 Scholarships Concordia University College of Alberta 1 Scholarship
Campus St. Jean 1 Scholarships Canadian University College (Alberta cohort) 1 Scholarship
University of Calgary 3 Scholarships Kings University College 1 Scholarship
University of Lethbridge 2 Scholarship St. Mary’s University 1 Scholarship
Mount Royal University 1 Scholarship Ambrose University 1 Scholarship

Deadline for Nominating Candidates: Contact the Student Awards Office

Page 394
 Languages In Teacher Education Scholarship - Nomination Form
Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the
Freedom of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your
eligibility for an award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions
about the collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

r Alberta Student Number (go to e d u c a tio n .g o v .a b .c a to find your ASN or to obtain one) Social Insurance Number A

Last Name (current full legal name) First Name and Middle Initial (current full legal name

Mailing Address (Include Apt. or Box Number) City/Town

Province Posta Code Area Code and Teler)hone Number Email Address

CITIZENSHIP (check one) r ALBERTA RESIDENCY (answ er both) “A

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta?
PERMANENT RESIDENT (Landed Immigrant) Y N Have you lived in Alberta for the last 12
N o te : Attach a photocopy o f perm anent resident card or
immigration long form. Visa students are not eligible consecutive months as a non full-time student?
OR Are you currently married to an Alberta
G e n d e r (c ir c le o n e ) Birthdate (Day/M onth/Year) resident?
IF Y O U H A V E A N S W E R E D ‘N O ’ T O B O T H Q U E S T IO N S ,
M F
___I___ ___I___ _ l ____I___I___ P L E A S E A T T A C H A L E T T E R E X P L A IN IN G Y O U R R E S ID E N C Y j

POST-SECONDARY EDUCATION
2014-2015 2015-2016
Name of-post-secondary institution

Name of program: Name of program:

Indicate your grade level of focus: Year of Program Year of Graduation

Elementary Education: _____ □ of □
Secondary Education: _____
Upon completion of your program, do you plan to teach in Alberta? Y N

Office Use Only

50 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD
D isb u rsem en t

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Nomination Form: To be completed by the school. Revised: Sept 2015

Page 395
 Nominee’s Language Background
For FNMI nominees, what learning/background will allow you to teach your
What is your first language/mother tongue? language and culture (e.g. at university, college, CILLDI, ATEP).

Indicate the language(s) you will be able to teach upon completion of your Alberta teacher preparation program:

Indicate where you plan to teach the above language(s) and why you want to teach languages:

Declaration of Nominee

r I have read and understand the instructions, and declare that:

a. all information provided is true and complete and I understand it is subject to audit,
" \

b. I am a full-time student in the last two years of an Alberta teacher preparation program at the institution named for the
period stated,
c. I intend to teach the language(s) above in Alberta upon completion of my Education program, and
d. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies or drop to part-time studies.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic record and enrollment status may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of determining my eligibility
for a scholarship,
b. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid Alberta
and for the use in research and statistical analysis in program evaluation.

I understand and agree that:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program,
however this is not a criterion for eligibility, and if I do not want to be identified, I will contact Studctn Aid Alberta.

Signature of Nominee (in ink) Today’s Date (in ink)

To Be Completed by Nominating Institution:

This confirms the above-named student has been nominated by this institution to receive a Languages in Teacher Education
Scholarship.
Name of Nominating Institution Date

Name of University Official Signature of University Official (in ink)

Students studying in French may also be eligible for the Fellowship for Full-time Studies in French.
Information is available at studentaid.alberta.ca/scholarships
Nomination Form: To be completed by the school.
Page 396
 Louise McKinney Post-Secondary Scholarship - Nomination Form
The Louise McKinney Post-Secondary Scholarship recognizes and rewards students for their academic achievements
and encourages them to continue in their undergraduate program o f study. Up to 1,400 scholarships are awarded
annually.

Scholarships are valued at $2,500 each.

Eligibility Criteria

For Alberta residents who plan to enroll at a university, college or technical institute, in the second or subsequent year
o f a full-time undergraduate or professional program. Students in graduate, part-time, apprenticeship or upgrading
programs are ineligible.

STUDENTS STUDYING IN ALBERTA

Students who are Alberta residents and continuing their full-time studies at an eligible post-secondary institution in
Alberta arc nominated by the Student Awards Office at the educational institution they most recently attended.
Nominations are based on academic standing and the scholarship policy o f the institution. Questions with respect to the
scholarship policy o f each institution should be directed to the Student Awards Office. Students who plan to change
educational institution or program should contact the Awards Office at the institution they are currently attending to
determine their eligibility.

STUDENTS STUDYING OUTSIDE ALBERTA

Alberta residents studying outside Alberta because their program of study is not offered in Alberta will be considered
for a scholarship in the second or subsequent year of study if their class standing is in the top two per cent o f their
program enrolment.

Application Procedure

STUDENTS STUDYING IN ALBERTA

Students currently enrolled full-time in a post-secondary program at an eligible Alberta post-secondary institution are
nominated for this scholarship by the Student Awards Office. To inquire about the nomination process, contact the
Student Awards Office.

STUDENTS STUDYING OUTSIDE ALBERTA

Students enrolled full-time at a post-secondary institution outside o f Alberta because their program o f study is not
available in Alberta must submit an academic transcript o f their previous year o f study. Send a completed application
to Student Aid Alberta at least eight weeks before the start o f the second or subsequent year o f study.
For more information contact Student Aid Alberta:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

The Louise McKinney Scholarship is funded through the Alberta Heritage Scholarship Fund. This program was created
by a $100 million endowment from the Alberta Heritage Savings Trust Fund and is designed to stimulate the pursuit of
excellence by rewarding outstanding achievement and assisting Albertans achieve their fullest potential.

Nomination Deadline for In-Province Students: Contact Student Awards Office

Page 398
 Louise McKinney Post-Secondary Scholarship - Nomination Form
Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under
the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this infomiation,
please contact Student Aid Alberta. PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

You may use the Learner Registry at e d u c a tio n .g o v .a b .c a to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

I I I I I I I I I I I I I I I Previous Surname _________________________

Province Country Postal Code Area Code Telephone Number

Gender ( c i r c l e one) Date of Birth Email Address

M
J ____ L
day m o n th year

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
N o t e : In c lu d e a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY*
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N
____ I____ ____ I____ l____ I____
m o n th year

PROPOSED POST-SECONDARY STUDIES

Name of Educational Institution Name of Program

Location (If outside Alberta, please provide com plete address.) Academic Year Start Date Year of Program

□ 1st
□
2nd
□
3 rd
□
4 th

Academic Year End Date

m o n th year

*If your parents do not currently reside in Alberta AND you have not lived in Alberta all your life, please include a letter
explaining the time spent in Alberta as a non full-time student.

Office Use Only

Revised: Oct 2015

Page 399
 Nominee’s Personal Information (continued)

EDUCATIONAL RECORD ( P le a s e lis t a ll u n iv e r s it ie s , c o lle g e s o r in s t it u t io n s a t t e n d e d to d a t e in c lu d in g y o u r c u r r e n t in s t it u t io n )

PERIOD OF STUDY INSTITUTION ENROLMENT STATUS

F r o m ( m m /y y ) T o (m m /y y ) N a m e o f I n s t it u t io n Program Y ear o f P rogram L e n g th o f P r o g r a m

Declaration of Applicant
I have read and understand the instructions, and declare that:
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

1 understand and agree that:

a. my personal information pertaining to my post-secondary academic record may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of
determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may be
released and exchanged by and between Student Aid Alberta and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Student Aid Alberta and
any provincial government departments, boards or institutions to verify the information I have
provided to Student Aid Alberta and for the use in research and statistical analysis in program
evaluation.
1 understand and agree that:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards can be obtained at: studentaid.alberta.ca/scholarships

Page 400
 Prairie Baseball Academy Scholarship - Nomination Form

The Prairie Baseball Academy Scholarship rewards the athletic and academic excellence of baseball players and provides an
incentive and means for these players to continue with their post-secondary education. Up to S40,000 in scholarships is available.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the Prairie Baseball Academy.

Award Value $500 to $2,000

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Permanent Resident and be an Alberta resident,
b. be a participant in the Prairie Baseball Academy,
c. be enrolled as a full-time student at a post-secondary institution in Alberta,
d. have achieved a grade point average of 2.0 on a 4.0 scale in the previous semester of study, and
e. be recommended by the Scholarship Committee of the Prairie Baseball Academy.

Selection Procedure

Application forms are available from the Prairie Baseball Academy and from Student Aid Alberta. Each nomination must include a
current transcript and attachments outlining the nominee’s extra curricular activities and future goals.

The Committee will select recipients based on academic standing, community involvement and baseball achievements.

Faxed applications are not accepted.

M ail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Sendee Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline is October 15

Page 402
 Prairie Baseball Academy Scholarship - Nomination Form

Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the
Freedom of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility
for an award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

Use the Learner Registry at: e d u c a tio n .g o v .a b .c a to find your Alberta Student N um ber or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

I I I I I I I I I I I I I I I Previous Surname ________________________

Province Country______________________ Postal Code Area Code Telephone Number

Gender ( c i r c l e o n e ) Date of Birth Email Address

M
J___ L
day m o n th year

CITIZENSHIP (check one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: A t ta c h a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd V is a s tu d e n ts a r e n o t e lig ib le .

ALBERTA RESIDENCY
Have you lived in Alberta for the last 12 consecutive months as a non full-time
Do your parents currently live
student before attending school full-time? O R Have you attended a post-
in Alberta?
secondary institution full-time in Alberta for the last two consecutive semesters?
I f y o u h a v e a n sw e re d “ N O ” to b o th “ re sid e n c y ”
q u e stio n s , p lea se in c lu d e a le tte r e x p la in in g y o u r tim e s p e n t in A lb e rta .

EDUCATIONAL RECORD (A c u r re n t a c a d e m ic tr a n s c r i p t m u st be in c lu d e d w ith th is n o m in a tio n fo rm )

N A M E O F H IG H S C H O O L T O W N /C IT Y P R O V IN C E YEAR CO M PLETED

N A M E O F P O S T -S E C O N D A R Y IN S T IT U T IO N FRO M TO PRO GRAM

Have you previously received a Prairie Baseball Academy Scholarship? YES

□ NO □
If yes, when _________________________________________________

Office Use Only

Revised: Oct 2015

Page 403
 Baseball Record of Nominee
Note: To be considered, players must be current members of the Prairie Baseball Academy,

a. List teams played for:

b. Statistical Record (past and current year)

c. Awards or distinctions received (Scholastic/Sports)

Please provide the following information on an attached page:

1. A short summary outlining your extra curricular activities within the community during the past few years. The statement should
be typed and no more than one page in length, and
2. A brief outline of your future plans/goals. This should also be typed and no longer than one page.

Declaration of Nominee
1 h a v e re a d a n d u n d e r s ta n d th e in s tru c tio n s , a n d d e c la re th a t:
a. All information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before completing one semester of studies.

I u n d e r s ta n d a n d a g re e th a t:
a. My personal information pertaining to my high school academic record may be released and exchanged by and between Alberta Education and
Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. My personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and between
Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. My personal information may be released and exchanged by and between Student Aid Alberta and any provincial government departments,
boards or institutions to verify the information I have provided to Student Aid Alberta and for the use in research and statistical analysis in
program evaluation.

I u n d e r s ta n d a n d a g re e th a t:
If I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a criterion for
eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

This Section is to be Completed by the Prairie Baseball Academy

I hereby confirm the Prairie Baseball Academy acknowledges that this nominee is a member and meets all terms and conditions of
this scholarship.

Name of Official:________________________________________________ Position: __________________________________

Signature of Official: ____________________________________________

Page 404
 Robert C. Carson Memorial Bursary - Nomination Form

T he R obert C. C arson M em orial B ursary w as established by the M inistry o f Justice and Solicitor G eneral and
recognizes and rew ards academ ic achievem ent at the post-secondary level.

Award Value

Five bursaries o f $500 each. O ne aw ard w ill be allocated to each o f the follow ing institutions:
Lethbridge C ollege, M ount Royal U niversity, M acE w an U niversity, U niversity o f A lberta
and U niversity o f Calgary.

Eligibility Criteria

A nom inee m ust:

a. be a C anadian citizen or P erm anent R esident,

b. be a resident o f A lberta for at least three years,
c. be enrolled full-tim e in the Law E nforcem ent or C rim inal Justice D iplom a program at Lethbridge
C ollege, M ount Royal U niversity, or M acE w an U niversity, or the Law program at the U niversity o f
C algary o r the Law or C rim inology program at the U niversity o f A lberta, and
d. have com pleted one year o f the program and continuing into the second year.

In addition, preference w ill be given to aboriginal students w ho are not receiving sponsorship. H ow ever, all
non-sponsored students w ill be considered for the bursary.

Selection Procedure

Q ualifying students at each institution w ill be contacted by the Student A w ards O ffice to com plete an
application form . N om inations w ill then be forw arded to Student A id A lberta for review and final approval.

Nomination Deadline: September 30

Information on other awards is available on: studentaid.alberta.ca/scholarships

Page 406
 Robert C. Carson Memorial Bursary - Nomination Form
Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award
under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this
information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Nominee’s Personal Information

Alberta Student Number ( 2 0 to w w w .e d u c a tio n . 2ov.a b .ca to find vourASN or to obtain one) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use unner and lower case. First Name and One Initial (current full legal nam e)

Mailing Address (Include Apt. or Box Number) City/Town

Province Countr/ Postal Code \rea Code Telephone Number

Gender ( c ir c le o n e ) Birthdate Email Address

M F
d a f ____
m oipth
1
_____ l J Z 1 ____ _____

CITIZENSHIP (check one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: A tta c h a p h o to c o p y o f p e r m a n e n t r e s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Does one parent currently reside in Alberta? Have you lived in Alberta all your life? N
IF Y O U H A V E A N S W E R E D “ N O ” T O B O T H Q U E S T IO N S , If no, since n th
P L E A S E IN C L U D E A L E T T E R E X P L A IN IN G T H E T IM E Y O U JL l vci" i
S P E N T IN A L B E R T A A S A N O N F U L L -T IM E S T U D E N T .

Arc you First Nations, Metis, or Inuit? Yes___ No ____

POST-SECONDARY STUDIES Are you being sponsored? Yes ___ No ___
(Sponsorship excludes student loan funding.)
Name of Institution

Name of Program Start Date for Program Year of Program (first, second, third)

mejinth
1
_____ ____ y f a r 1_____

Revised: Oct 2015

Page 407
 Declaration of Nominee

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my post-secondary academic record may be released and exchanged by and between
Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information 1 have provided to Student Aid Alberta,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this
is not a criterion for eligibility, and if I do not want to be identified I will contact Student Aid Alberta.

Signature of Applicant Today’s Date (in ink)

To be Completed by the Nominating Institution

I hereby declare that this individual m eets all eligibility requirem ents for this bursary and is currently
enrolled as a full-tim e student.

Name of Institution Official: ---------------------------------------------------------------

Position: -----------------------------------------------------------------------

Signature of Official: ----------------------------------------------------

Phone Number: -------------------------------------------

Date: -----------------------------------------

Page 408
Parental* Personal and Financial Information 2015/2016 Schedule 1
*T h is in c lu d e s p a re n ts a n d s te p p a re n ts .
Complete Schedule 1 if:
15/16 S1
• you are single and have been out of high school for less than 4 years, and • you have not been available for full-time work for 2 or more
years since you left high school
Applicant’s Last Name Initials Social Insurance Number

P a rt A (M a n d a to ry ) - To D e te rm in e P ro v in c ia l R e s id e n c y

Are BOTH of your parents deceased or do you have a court appointed legal
| Yes _ | No
guardian? (If yes, do not complete the remainder of Schedule 1)
Does at least one of your parents reside in Alberta? 1 Yes I No
• If your parents do not live in Alberta, where do they currently reside?
Prov/State Country

_L

M o n th Year
If your parents do not live in Alberta, indicate the date they moved out of Alberta
_l_____l_ I
____ ___
If your parents have moved out of Alberta, did you stay
| Yes L I No
in Alberta to begin or continue post-secondary studies?
I wish to be considered for federal grants and loans, i Yes I No
and the Alberta Low Income Grant. (See Quick Tips, p.6) ,_____________
If yes, continue to Part B

P a rt B (O p tio n a l) - To D e te rm in e Y o u r E lig ib ility fo r F e d e ra l G ra n ts a n d L o a n s , a n d A lb e rta L o w In c o m e G ra n t

You must complete Part B if you wish to be considered
for federal loans and the following grants:
• Federal grant for Students from Low-Income Families
($250 per month of studies)
• Federal grant for Students from Middle-Income Families
($100 per month of studies)
Federal grant for Students with a Permanent Disability
($2,000 per academic year)
Federal grant for Services and Equipment for Students with
a Permanent Disability (up to $8,000 per academic year)
Alberta Low Income Grant ($250 per month of studies)

Notice: If your parent(s) do not wish to share their personal information with you to complete Part B, they may contact the Student
Aid Alberta Service Centre toll free at 1-855-606-2096 for further instructions.

Parent 1 Last Name Parent 1 First Name

Parent 2 Last Name Parent 2 First Name

Is there a public transit system available from your parents’ home to the school you will be attending? Yes J No
(This does not include Greyhound, Red Arrow, etc.)
Family Size • include all children 0-17 years • include parent 1 & 2 as listed above
• include children 18-22 (if they are full-tim e students) • do not include children over age of 22

Number of people in your family

Number of children attending post-secondary institutions in 2015/2016

Parental Total Income (see Quick Tips, p.13 #6)

Parent 1 Total income (Line 150 of 2014 Income Tax Return)

Parent 2 Total income (Line 150 of 2014 Income Tax Return)

Reduced Parental Total Income Fill in this section if either parent’s annual income from all sources (work, government or other)
is expected to be lower than Parental Total Income from line 150 above.

Parent 1 estimated yearly income

Parent 2 estimated yearly income

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using e-Document Upload
Or MAIL to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4
Page 409
 Page A

P A R T -T IM E A P P L IC A T IO N FOR P O S T -S E C O N D A R Y S T U D IE S

Eligibility Requirements for Part-Time Loans and Grants:
• you must be a resident of Alberta. This means that:
- Alberta is the last province you have lived in for 12
consecutive months while not a full-time post-secondary
student, or
- you are living in Alberta and have never lived in any
Canadian province for 12 months in a row. In this case,
submit a Residency Resume (studentaid.alberta.ca)
and/or a letter to explain your residency situation.
• you must demonstrate financial need
• eligibility for student aid is determined by using an income
threshold table based on line 150 of your and your spouse's/
partner's (if applicable) income tax return. Your combined
income must be less than the amounts listed in the
charts below.
• any federal or provincial loans you have must be in
good standing
• courses must be part of an approved program of study
and taken for credit
Tips to Complete Your Application
• Apply at least 6-8 weeks before your course(s) start.
• Ensure Student Aid Alberta receives this application at least
30 days before this year’s program ends in order to process.
• Section 5 of this application must be completed by your
educational institution.
• Part-time student aid is intended to help cover the cost of
tuition, books, travel, and daycare (if applicable).
• If you have received previous part-time student aid, you must
successfully complete all courses to receive student aid on a
subsequent application.

IMPORTANT NOTICE - If you have Alberta Student Loans, have your educational institution complete a Confirmation
of Registration (Form B) form to reinstate your loans to interest-free status.

In the Charts Below

• Family size means you, your spouse/partner, and your dependent children (if applicable).
• If your family income last year was higher than the amounts listed in the charts but is now lower, you may provide an explanation
of your situation and documentation of your current income.

A LB E R T A PAR T-TIM E G R A N T *
"You must be attending an educational institution in Alberta.

Students attending a post-secondary institution may be eligible for up to $600 per semester. The maximum student aid available
for one calendar year is $1,800.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $46,283 $64,796 $77,664 $86,787 $93,873 $99,656 $104,548

PAR T-TIM E C A N A D A S T U D E N T LO A N *
*Your balance cannot exceed $10,000 at any time.

Additional Eligibility Criteria to receive maximum $10,000

• must be enrolled in 20 - 59% of a full-time course load

Family Size 1 2 3 4 5 6 7 or more

Income Limit $46,283 $64,796 $77,664 $86,787 $93,873 $99,656 $104,548

C A N A D A S T U D E N T G R A N T FOR P AR T-TIM E S T U D IE S

Additional Eligibility Criteria to receive up to $600 per semester (up to a maximum of $1,200 annually) in grant funding
• must be enrolled in 20 - 59% of a full-time course load

Family Size 1 2 3 4 5 6 7 or more

Income Limit $23,978 $29,852 $36,700 $44,557 $50,537 $56,996 $63,457

Page 410
 Page B

C A N A D A S T U D E N T G R A N T FOR P ER SO N S W IT H P E R M A N E N T D IS A B IL IT IE S

Additional Eligibility Criteria

• must have part-time Canada Student Loan eligibility
• must be a person with a permanent disability as defined by the Canada Student Loan Program
• must provide acceptable documentation of permanent disability as required by the Canada Student Loan Program
• must complete a Schedule 4. The Disability Advisor at your school may be authorized to sign your Schedule 4.
Check with the Advisor first for assistance and further instructions.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $46,283 $64,796 $77,664 $86,787 $93,873 $99,656 $104,548

C A N A D A S T U D E N T G R A N T FOR SE R V IC E S A N D E Q U IP M E N T
FOR P ER SO N S W IT H P E R M A N E N T D IS A B IL IT IE S

Additional Eligibility Criteria

• must have part-time Canada Student Loan eligibility
• must have a need for exceptional education-related services or equipment required to participate in post-secondary studies
• must provide acceptable documentation of permanent disability as required by the Canada Student Loan Program
• must complete a Schedule 4. The Disability Advisor at your school may be authorized to sign your Schedule 4.
Check with the Advisor first for assistance and further instructions.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $46,283 $64,796 $77,664 $86,787 $93,873 $99,656 $104,548

FOR A L L S T U D E N T A ID IN Q U IR IE S C A L L T H E S T U D E N T A ID A L B E R T A SER VIC E C EN TR E:

• 1 8 5 5 -6 0 6 -2 0 9 6 (to ll fre e fro m a n y w h e re in N o rth A m e ric a )

• 1 8 5 5 -3 0 6 -2 2 4 0 (TTY fo r th e h e a rin g im p a ire d )
• 800 2 5 2 9 -9 2 4 2 (o u ts id e N o rth A m e ric a - a d d th e a p p ro p ria te in te rn a tio n a l a c c e s s c o d e )

You may be asked to provide your Social Insurance Number, Alberta Student Number (ASN), and/or School Identification Number.
Please have these numbers available for reference.

If you do not know your ASN, or do not yet have an ASN, search for "Alberta Student Number" at education.alberta.ca and enter the
Learner Registry. You can also call toll-free in Alberta at 310-0000 to have a Request for Alberta Student Number form mailed
to you. Due to privacy issues, ASN's will not be given over the phone.

For further assistance:

• Contact the Financial Aid Office at the school you plan to attend
• Visit studentaid.alberta.ca

S T U D E N T A ID A L B E R T A M A IL IN G A D D R E S S

STUDENT AID ALBERTA

PO BOX 28000 STN MAIN
EDMONTON AB T5J 4R4

Page 411
 Student Aid Alberta
Canada Application for Financial Assistance for Student Aid Alberta

Part-Time Post-Secondary Studies 2014/2015

(Taking less than 60% o f a Full Course Load) 1 4 /1 5 P
• Student Aid Alberta must receive this application at least 30 days before this year’s program ends in order to process.
• If you are a student with a permanent disability and need to submit a Schedule 4, print a Schedule 4 from studentaid.alberta.ca

SECTION 1 - PERSONAL INFORMATION

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) Initial Gender Q Male □ Female

If you have changed your name since you last applied,

□ Birthdate
Day M o n th Year

_ l _____ I______I_____ I_____ I_____ I______I______L

provide legal documentation.
Marital Status: (check one)
Apartment or Box Number (for definition of dependent children, see Section 3)
Q Single (no dependent children)
Street Address I i Single (with dependent children)
I I Separated/Divorced/Widowed (no dependent children)
I \ Separated/Divorced/Widowed (with dependent children)
City/Town
Q Married
I i Common Law
Prov/State Country Postal/Zip Code You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal
relationship continuously for the past one year, or
Telephone (format: 999-999-9999)
• you have declared an individual to have a status
_L equivalent to that of your common law partner under
any law of Alberta or of Canada, or
Alternate Telephone (format: 999-999-9999)
• you and an individual are living together in a conjugal
JL relationship where there are one or more children of
the relationship by birth or adoption.
Email Address
Maiden Name (if applicable)

Citizenship Status: (check one)

(Students with a study permit are not eligible for financial Date completed/last attended regular High School
assistance from Student Aid Alberta) (excludes upgrading)
M o n th Year
□ Canadian
______I______I______I______I______I______ I_____
□ Permanent Resident (Landed Immigrant)
Your Alberta Student Number (mandatory)
□ Convention Refugee* (see explanation on bottom right)
(obtained from Alberta High School Transcript)
Have you lived in Alberta all your life? Q Yes Q No
If no, is Alberta the last province you have
lived in for 12 consecutive months without
being a full-time post-secondary student? Q Yes Q No 'Students who are Protected Persons, including
Convention Refugees, may be eligible for student aid.
The following question is optional. Your answer will not affect You must submit:
your eligibility for funding. Innovation and Advanced Education • A copy of your Social Insurance Number card
uses personal information on Aboriginal students to measure the
effectiveness of student financial assistance programs in relation AND a copy of one of the following:
to Aboriginal students and to research programs and services • Notice of Decision, or
to improve student success rates. If you wish to declare your
• Verification of Status Document (VOS)
Aboriginal heritage, please specify (optional):
These documents must not expire before the end of your
□ Status Indian/First Nations □ Metis
current study period.
□ Non-Status Indian/First Nations Q Inuit

0 8 /1 5 A P P - T Y P E 11 A P P - Y E A R 2 0 1 4 /2 0 1 5 A P P -F O R M -D F o r O f f ic e U s e O n ly A p p ID Pa le 412
 Page 2

S E C T IO N 2 - E M E R G E N C Y C O N T A C T IN F O R M A T IO N

Student Aid Alberta will contact the person below to obtain your new address, phone number or email address if unable to contact you
using the information you provided on page 1.

Last Name City/Town

I I I I l I I I I I I I I l l I I
M id d le
First Name_____________________________________ in itial

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 n
Apartment or Box Number

Street Address

S E C T IO N 3 - D E P E N D A N T S

Dependent children mean those children who are living with you and
fo r whom you and/or your spouse/partner are legally responsible.

Number of dependants) between 0 - 1 1 years of age

Number of dependant(s) between 12 -1 8 years of age

'Provide documentation of care required for

Number of dependant(s) with a permanent disability, aged 12 or older*
your dependant with a permanent disability.

How much is your monthly childcare cost (after subsidy) for those children
11 years old or younger, or children 12 - 18 who have a permanent disability?

Page 413
 Page 3

E d u c a tio n a l In s titu tio n In fo rm a tio n

Name of School

P ro g ra m O u tc o m e
Do not complete - for Student Aid Alberta use only
□ Certificate
School Code
□ Diploma
□ Degree Campus Code
□ Degree - Masters
Program Code
□ Degree - Doctoral

NOTE: This application for student aid can cover part-time studies for up to 12 months, however, if the student is enrolled in more than
one (1) course and there is a 30 day gap between courses, the student must apply for student aid again on a separate application.

Is the student enrolled in a correspondence/e-learning/distance study program? □ Yes □ No

School Student ID Number i i i i i i i i i i i

Start End
D ay M o n th Year D ay M o n th Y ear
Study Dates
■ ■ l ___ 1_____ 1_____ 1____ ■ ■ 1
___ 1_____ 1_____ 1____

School Stamp
Program Information N o. o f * B o o k /S u p p ly C o s ts
’ T u itio n a n d /o r F ees
C o u rs e s (In c lu d e s R e n ta ls )

___ 1___ 1___ 1___ ____ 1____ 1____ 1____

*R o u n d to the n e a re st d o lla r

List Course(s) for Current Study Period (mandatory) Only list courses for which the student will receive credit.

Signature of School Official Title of School Official Today’s Date

D ay M o n th Y ear

X
_ l I ,■ 1 _ l ___1___1___
Printed Name of School Official Area Code Telephone Number Area Code Fax Number

J____L
Page 414
 Page 4

S E C TIO N 6 - A D D IT IO N A L IN F O R M A T IO N R EQ U IR E D

Do you want to be considered for a Part-time Canada Student Loan? Q Yes Q No

I have had a Canada Student Loan □ Yes □ No

I have defaulted on my previous Full-time or Part-time Canada Student Loan □ Yes Q No □ Not Applicable

I still owe on a Part-time Canada Student Loan □ Yes □ No

• If yes, indicate the outstanding amount of principal and interest still owed $

I have previously received funding for Part-time studies. □ Yes □ No

• If yes, did you pass the course(s)? □ Yes □ No
Are you a student with a permanent disability(ies)? □ Yes □ No
If yes, you may qualify for the Canada Student Grant for Persons with Permanent Disabilities.

If yes, and you require assistive services or equipment, you may qualify for the Canada Student Grant for Services and Equipment
for Persons with Permanent Disabilities.

To apply for either federal grant, you must complete a Schedule 4. For assistance or more information,
see the Disability Advisor at your school.

S E C TIO N 6A - R EQ U ESTED N EED - you can enter an am o unt below o r , if y o u l e a v e it b l a n k , a c a l c u l a t io n w il l b e d o n e

Total Part-time assistance requested

NOTE: This student aid is intended to help cover the cost of tuition, books, travel and daycare (if applicable).

S E C TIO N 7 - A P P L IC A N T C O N S E N T A N D D E C LA R A T IO N

Innovation and Advanced Education is collecting the personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for financial assistance,
to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial
Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with the Freedom of Information and Protection of Privacy Act (Alberta).

The personal information in this Application may be disclosed to:

• federal government departments or agencies (including
Employment and Social Development Canada) to verify any
information you have provided, to determine your eligibility for
financial assistance, to administer student financial assistance
programs, and to conduct research, statistical analysis, and
evaluations related to student financial assistance programs;
educational institutions to verify any information you have
provided, to determine your eligibility for financial assistance,
to assist your educational institution to respond to your
inquiries concerning the status of your Application and to
administer student financial assistance programs;
any credit bureau to verify any information you have provided,
to determine your eligibility for financial assistance and to
administer student financial assistance programs.

If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre
toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4FI4.

A P P L IC A N T C O N S E N T A N D D E C LA R A T IO N c o n tin u e s o n P a g e 5
S ig n a tu re s R e q u ire d o n P a g e 5 Page 415
 Page 5
S E C T IO N 7 - A P P L IC A N T C O N S E N T A N D D E C LA R A T IO N - CONTINUED FROM PAGE 4
I declare that:
• the information provided by me in this Application, and all
applicable schedules, is true and complete, including all
financial information, and I understand that the information
that I have provided is subject to review and assessment
by the Minister of Innovation and Advanced Education
in accordance with the Student Financial Assistance Act
(Alberta), the Canada Student Loans Act and the Canada
Student Financial Assistance Act.
• I will use any financial assistance awarded to me towards
the cost of my education.
• I have not applied to another province or territory for student
financial assistance for the same period for which I am
applying for funding in this Application.
I agree to:
• provide information or documents as requested by
Innovation and Advanced Education to verify any statements
made in this Application.
• immediately notify Innovation and Advanced Education in
writing of any change in my address, marital or common law
partner status, financial circumstances, academic status or
study period.
• repay my loan in full.
I understand that:
• I may be required to immediately repay any financial
assistance I receive if there are any changes to my financial
circumstances, marital or common law partner status,
academic status or study period.
• I may be denied financial assistance if I fail to notify
Innovation and Advanced Education in writing of any
change in my financial circumstances, marital or common
law partner status, academic status or study period, or
fail to provide documents or information as requested by
Innovation and Advanced Education to verify statements
made in this Application.
• if I make a false or misleading statement in this Application,
or fail to disclose information as requested by Innovation and
Advanced Education, I may be denied financial assistance,
and/or required to immediately repay all financial assistance
received, and/or subject to criminal prosecution.
I have read, understood, and agree to be bound by all of the consents and declarations contained within pages 4 and 5
of this Application.
Applicant Signature
• I am not entitled to apply for or receive financial assistance
from another province or territory for the same period of time
that I am getting financial assistance from Innovation and
Advanced Education.
• failure to disclose information or provide updated information
as requested by Innovation and Advanced Education may
constitute the making of a false or misleading statement.
• Innovation and Advanced Education has the right to recover
benefits I receive which I am not entitled to, including any
benefits received due to administrative errors.
If I receive financial assistance, I acknowledge the authority
of, and where a consent is required hereby irrevocably
authorize the Minister to disclose and exchange my
personal information with:
• the Government of Canada, the National Student Loans
Service Centre, any provincial or territorial government
department or agency, any lending institution where
I may have a student loan, any educational institution
or credit bureau for any purpose related to the verification
of information provided by me and for administration
and enforcement related to student financial assistance
programs;
• Employment and Social Development Canada through the
Social Insurance Registry to verify my Social Insurance
Number, name, date of birth, and gender solely to confirm
identification for the purpose of financial assistance;
• Alberta Human Services to operate and administer financial
assistance programs, including determining my eligibility,
and the eligibility of my spouse/partner, for financial
assistance;
• any of the following: lending institutions; credit bureaus; the
educational institution(s) named in the Application; and any
third party authorized to collect a debt owed to Her Majesty
the Queen in right of Alberta, in each case for any purpose
relating to administration, enforcement or collection related
to student financial assistance programs;
• federal government departments or agencies or the
educational institution(s) named in the Application to
conduct research, statistical analysis, and evaluations
related to student financial assistance programs.
Today’s Date
D ay M o n th Y ear
I I
___ I___ ___ I___ I___ ___ I___ I___ I___
Page 416
 Page 6

SPOUSE/PARTNER DECLARATION

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) (“ FOIP”) to determine and verify the Applicant’s eligibility for financial
assistance, to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance
programs in accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student
Financial Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is
managed in accordance with FOIP.

The personal information may be disclosed to:

• federal, provincial or territorial government departments or • any lending institution or credit bureau to verify any
agencies or educational institutions named in this Application, information the Applicant provided, to determine the eligibility
to verify information the Applicant provided, determine the of the Applicant for financial assistance and to administer
eligibility of the Applicant for financial assistance and to student financial assistance programs.
administer student financial assistance programs.
• the Applicant for the purposes of determining and verifying
• the federal government for use in research, statistical the Applicant’s eligibility for financial assistance.
analysis and evaluations related to student financial
assistance programs.
• Alberta Human Services to operate and administer financial
assistance programs, including your eligibility, and the
eligibility of the Applicant, for financial assistance.

If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll
free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Spouse/Partner Declaration
• I declare that my personal information included on this form is true and complete.

Signature of Spouse/Partner (if applicable) Today’s Date

D ay M o n th Y ear
X
_ i _ l i l l i i i

STUDENT AID ALBERTA M AILING ADDRESS

STUDENT AID ALBERTA

PO BOX 28000 STN MAIN
EDMONTON AB T5J 4R4

Page 417
 Page A

S tu d e n t A id O p tio n s fo r P art-T im e P o st-S e co n d a ry S tudents

Eligibility Requirements for Part-Time Loans and Grants:
• you must be a resident of Alberta. This means that:
- Alberta is the last province you have lived in for 12
consecutive months without being a full-time post­
secondary student, or
- you are living in Alberta and have never lived in any
Canadian province for 12 months in a row. In this case,
submit a Residency Resume (studentaid.alberta.ca)
and/or a letter to explain your residency situation.
• you must demonstrate financial need
• eligibility for student aid is determined by using an income
threshold table based on line 150 of your and your spouse's/
partner's (if applicable) income tax return. Your combined
income must be less than the amounts listed in the
charts below.
Tips to Complete Your Application
• Apply at least 6-8 weeks before your course(s) start.
• Ensure Student Aid Alberta receives this application at least
30 days before this year's program ends in order to process.
• Part-time student aid is intended to help cover the cost
of tuition, books, travel, and daycare (if applicable).
• If you have received previous part-time student aid, you must
successfully complete all courses to receive student aid on a
subsequent application.
• Section 5 of this application must be completed and signed
by your educational institution.
Faxed or scanned documents are not accepted.
You must provide an original signature.

• any federal or provincial loans you have must be in

good standing
• courses must be part of an approved program of study
and taken for credit

Important Notice - If you have Alberta Student Loans, have your educational institution complete a Confirmation
of Registration (Form B) form to reinstate your loans to interest-free status.

For A ll S tu d e n t A id In q u irie s C all th e S tu d e n t A id A lb e rta S ervice C entre:

• 1 855-606-2096 (toll fre e fro m anyw here in N orth A m erica)
• 1 855-306-2240 (TTY fo r th e hearing im paired)
• 800 2 529-9242 (outside N o rth A m e rica - add th e a p p ro p ria te in te rn a tio n a l a ccess code)

You may be asked to provide your Social Insurance Number, Alberta Student Number (ASN), and/or School Identification Number.
Please have these numbers available for reference.
If you do not know your ASN, or do not have an ASN, go to: iae.alberta.ca/ASN
You can also call toll-free in Alberta at 310-0000 to have a Request for Alberta Student Number form mailed to you. Due to privacy
issues, ASN’s will not be given over the phone.

For further assistance:

• Contact the Financial Aid Office at the school you plan to attend
• studentaid.alberta.ca

S tu d e n t A id A lb e rta M ailing A ddress

STUDENT AID ALBERTA

PO BOX 28000 STN MAIN
EDMONTON AB T5J 4R4

Page 418
 Page B

In the Charts Below

• Family size means you, your spouse/partner, and your dependent children (if applicable).
• If your family income last year was higher than the amounts listed in the charts but is now lower, you may provide an explanation
of your situation and documentation of your current income.

A lb e rta P art-T im e G rant*

*You must be attending an educational institution in Alberta.

Students attending a post-secondary institution may be eligible for up to $600 per semester. The maximum student aid available
for one calendar year is $1,800.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $47,486 $66,481 $79,683 $89,043 $96,314 $102,247 $107,266

P a rt-T im e C anada S tu d e n t Loan*

*Your balance cannot exceed $10,000 at any time.

Additional Eligibility Criteria to receive maximum $10,000

• must be enrolled in 20 - 59% of a full-time course load

Family Size 1 2 3 4 5 6 7 or more

Income Limit $47,486 $66,481 $79,683 $89,043 $96,314 $102,247 $107,266

C anada S tu d e n t G rant fo r P art-T im e S tudies

Additional Eligibility Criteria to receive up to $600 per semester (up to a maximum of $1,200 annually) in grant funding
• must be enrolled in 20 - 59% of a full-time course load

Family Size 1 2 3 4 5 6 7 or more

Income Limit $24,601 $30,628 $37,654 $45,715 $51,851 $58,478 $65,107

C anada S tu d e n t G rant fo r Persons w ith P erm anent D isa b ilitie s

Additional Eligibility Criteria

• must have part-time Canada Student Loan eligibility
• must be a person with a permanent disability as defined by the Canada Student Loan Program
• must provide acceptable documentation of permanent disability as required by the Canada Student Loan Program
• must complete a Schedule 4 the first time you are applying as a student with a documented permanent disability. The Disability
Advisor at your school may be authorized to sign your Schedule 4. Check with the Advisor first for assistance and further instructions.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $47,486 $66,481 $79,683 $89,043 $96,314 $102,247 $107,266

C anada S tu d e n t G rant fo r S ervices and E quipm en t

fo r P ersons w ith P erm anent D isa b ilitie s

Additional Eligibility Criteria

• must have part-time Canada Student Loan eligibility
• must have a need for exceptional education-related services or equipment required to participate in post-secondary studies
• must provide acceptable documentation of permanent disability as required by the Canada Student Loan Program
• must complete a Schedule 4 for each year that you apply for student aid. The Disability Advisor at your school may be authorized
to sign your Schedule 4. Check with the Advisor first for assistance and further instructions.

Family Size 1 2 3 4 5 6 7 or more

Income Limit $47,486 $66,481 $79,683 $89,043 $96,314 $102,247 $107,266

Page 419
 Student Aid Alberta
Canada Application for Financial Assistance For Student Aid Alberta
Part-Time Post-Secondary Studies 2015/2016
(Taking less than 60% o f a Full Course Load) 1 5 /1 6 P
• Student Aid Alberta must receive this application at least 30 days before this year’s program ends in order to process.

S ectio n 1 - P ersonal In fo rm a tio n

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) Initial Gender Q Male □ Female

If you have changed your name since you last applied,

□ Birthdate
D ay M o n th Y ear

_ l _____ I______I_____ I_____ I_____ I______I______L

provide legal documentation.
Marital Status: (check one)
Apartment or Box Number (for definition of dependent children, see Section 3)
Q Single (no dependent children)
Street Address I i Single (with dependent children)
I I Separated/Divorced/Widowed (no dependent children)
I \ Separated/Divorced/Widowed (with dependent children)
City/Town
Q Married
I i Common Law
Prov/State Country Postal/Zip Code You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal
relationship continuously for the past one year, or
Mobile Number (format: 999-999-9999) to receive text messages
• you have declared an individual to have a status
_L equivalent to that of your common law partner under
any law of Alberta or of Canada, or
Telephone Number (format: 999-999-9999)
• you and an individual are living together in a conjugal
JL relationship where there are one or more children of
the relationship by birth or adoption.
Email Address
Maiden Name (if applicable)

Citizenship Status: (check one)

(Students with a study permit are not eligible for funding from Date completed/last attended regular High School
Student Aid Alberta) (excludes upgrading)
M o n th Y ear
□ Canadian
□ Permanent Resident
___I___I___ I___ I___ I___ I__
Your Alberta Student Number (mandatory)
□ Protected Person* (see explanation on bottom right)
(obtained from Alberta Transcript of High School Achievement)
Have you lived in Alberta all your life? Q Yes Q No
If no, is Alberta the last province you have
lived in for 12 consecutive months without
being a full-time post-secondary student? Q Yes Q No 'Students who are Protected Persons, including
Convention Refugees, may be eligible for student aid.
The following question is optional. Your answer will not affect You must submit:
your eligibility for funding. Innovation and Advanced Education • A copy of your Social Insurance Number card
uses personal information on Aboriginal students to measure the
effectiveness of student financial assistance programs in relation AND a copy of one of the following:
to Aboriginal students and to research programs and services • Notice of Decision, or
to improve student success rates. If you wish to declare your
• Verification of Status Document (VOS)
Aboriginal heritage, please specify (optional):
These documents must not expire before the end of your
□ Status Indian/First Nations □ Metis
current study period.
□ Non-Status Indian/First Nations Q Inuit

0 8 /1 6 A P P - T Y P E 11 A P P - Y E A R 2 0 1 5 /2 0 1 6 A P P -F O R M -D For O ffic e U s e O n ly A p p ID Pa 420

 Page 2

S ectio n 2 - E m ergency C o n ta c t In fo rm a tio n

Student Aid Alberta will contact the person below to obtain your new address, phone number or email address if unable to contact you
using the information you provided on page 1.

Last Name City/Town

I I I I l I I I I I I I I l l I I
M id d le
First Name_____________________________________ in itia l

1111111111111111 n
Apartment or Box Number

Street Address

S ectio n 3 - D ependants

Dependent children mean those children who are living with you and
for whom you and/or your spouse/partner are legally responsible.

Number of dependants) between 0 - 1 1 years of age

Number of dependant(s) between 12 -1 8 years of age

'Provide documentation of care required for

Number of dependant(s) with a permanent disability, aged 12 or older*
your dependant with a permanent disability.

How much is your monthly childcare cost (after subsidy) for those children
11 years old or younger, or children 12 - 18 who have a permanent disability?

Page 421
 Page 3

E du ca tio n a l In s titu tio n In fo rm a tio n

Name of School

P rogram O utco m e
□ Certificate □ Diploma □ Degree □ Degree - Masters □ Degree - Doctoral

Note: This application for student aid can cover part-time studies for up to 12 months, however, if the student is enrolled in more than
one course and there is a 30 day gap between courses, the student must apply for student aid on a separate application.

Is the student enrolled in a correspondence/e-learning/distance study course(s)? □ Yes Q No

School Student ID Number i i i i i i i i i i i

Start End
D ay M o n th Year D ay M o n th Y ear
Study Dates
____ L____ L ■ ■ I ___ I_____ I_____ I____ ^ _ L , I ___ I_____ I_____ I____

School Stamp
Program Information N o. o f 'B o o k /S u p p ly C o s ts
'T u itio n a n d /o r F e e s
C o u rs e s (In c lu d e s R e n ta ls )

___ I___ I___ I___ ____ I____ I____ I____

*R o u n d to the n e a re st d o lla r

List Course(s) for Current Study Period (mandatory) Only list courses for which the student will receive credit.

Signature of School Official Title of School Official Today’s Date

D ay M o n th Y ear
X
___ L I I _L 1 1 1 1
Printed Name of School Official Area Code Direct Telephone Number Email Address

___I___L ___I___I___I___I___I___I___I___
Page 422
 Page 4

Section 6 - Additional Information Required

Do you want to be considered for a Part-time Canada Student Loan? Q Yes Q No

I have had a Canada Student Loan □ Yes □ No

I have defaulted on my previous Full-time or Part-time Canada Student Loan □ Yes Q No □ Not Applicable

I still owe on a Part-time Canada Student Loan □ Yes □ No □ Not Applicable

• If yes, indicate the outstanding amount of principal and interest $ i i i i

Q Yes Q No

• If yes, did you pass the course(s)? □ Yes □ No

Are you a student with a permanent disability? Q Yes I | No

• If yes, you may qualify for the Canada Student Grant for Persons with Permanent Disabilities.

• If yes, and you require assistive services or equipment, you may qualify for the Canada Student Grant for Services and Equipment
for Persons with Permanent Disabilities.

• To apply for either federal grant, you must complete a Schedule 4. For assistance or more information,
see the Disability Advisor at your school.

Section 6A - Requested Need - Y o u c a n e n t e r a n a m o u n t b e lo w or, if y o u le a v e it b la n k , a c a lc u la tio n w ill b e d o n e

Total Part-time assistance requested

NOTE: This student aid is intended to help cover the cost of tuition, books, travel and daycare (if applicable).

Section 7 - Applicant Consent and Declaration

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) to determine and verify your eligibility for financial assistance,
to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial
Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with the Freedom of Information and Protection of Privacy Act (Alberta).

The personal information in this Application may be disclosed to:

• federal government departments or agencies (including
Employment and Social Development Canada) to verify any
information you have provided, to determine your eligibility for
financial assistance, to administer student financial assistance
programs, and to conduct research, statistical analysis, and
evaluations related to student financial assistance programs;
educational institutions to verify any information you have
provided, to determine your eligibility for financial assistance,
to assist your educational institution to respond to your
inquiries concerning the status of your Application and to
administer student financial assistance programs;
any credit bureau to verify any information you have provided,
to determine your eligibility for financial assistance and to
administer student financial assistance programs.

If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre
toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4FI4.

Applicant Consent and Declaration continues on Page 5

Signatures Required on Page 5 Page 423
 Page 5
Section 7 - Applicant Consent and Declaration - Continued from page 4
I declare that:
• the information provided by me in this Application, and all
applicable schedules, is true and complete, including all
financial information, and I understand that the information
that I have provided is subject to review and assessment
by the Minister of Innovation and Advanced Education
in accordance with the Student Financial Assistance Act
(Alberta), the Canada Student Loans Act and the Canada
Student Financial Assistance Act.
• I will use any financial assistance awarded to me towards
the cost of my education.
• I have not applied to another province or territory for student
financial assistance for the same period for which I am
applying for funding in this Application.
I agree to:
• provide information or documents as requested by
Innovation and Advanced Education to verify any statements
made in this Application.
• immediately notify Innovation and Advanced Education in
writing of any change in my address, marital or common law
partner status, financial circumstances, academic status or
study period.
• repay my loan in full.
I understand that:
• I may be required to immediately repay any financial
assistance I receive if there are any changes to my financial
circumstances, marital or common law partner status,
academic status or study period.
• I may be denied financial assistance if I fail to notify
Innovation and Advanced Education in writing of any
change in my financial circumstances, marital or common
law partner status, academic status or study period, or
fail to provide documents or information as requested by
Innovation and Advanced Education to verify statements
made in this Application.
• if I make a false or misleading statement in this Application,
or fail to disclose information as requested by Innovation and
Advanced Education, I may be denied financial assistance,
and/or required to immediately repay all financial assistance
received, and/or subject to criminal prosecution.
1have read, understood, and agree to be bound by all of the consents and declarations contained within pages 4 and 5
of this Application.
Applicant Signature
• I am not entitled to apply for or receive financial assistance
from another province or territory for the same period of time
that I am getting financial assistance from Innovation and
Advanced Education.
• failure to disclose information or provide updated information
as requested by Innovation and Advanced Education may
constitute the making of a false or misleading statement.
• Innovation and Advanced Education has the right to recover
benefits I receive which I am not entitled to, including any
benefits received due to administrative errors.
If I receive financial assistance, I acknowledge the authority
of, and where a consent is required hereby irrevocably
authorize the Minister to disclose and exchange my
personal information with:
• the Government of Canada, the National Student Loans
Service Centre, any provincial or territorial government
department or agency, any lending institution where
I may have a student loan, any educational institution
or credit bureau for any purpose related to the verification
of information provided by me and for administration
and enforcement related to student financial assistance
programs;
• Employment and Social Development Canada through the
Social Insurance Registry to verify my Social Insurance
Number, name, date of birth, and gender solely to confirm
identification for the purpose of financial assistance;
• Alberta Human Services to operate and administer financial
assistance programs, including determining my eligibility,
and the eligibility of my spouse/partner, for financial
assistance;
• any of the following: lending institutions; credit bureaus; the
educational institution(s) named in the Application; and any
third party authorized to collect a debt owed to Her Majesty
the Queen in right of Alberta, in each case for any purpose
relating to administration, enforcement or collection related
to student financial assistance programs;
• federal government departments or agencies or the
educational institution(s) named in the Application to
conduct research, statistical analysis, and evaluations
related to student financial assistance programs.
Today’s Date
Day Month Year
1 1
___ 1___ ___ 1___ 1___ ___ 1___ 1___ 1___
Page 424
 Page 6

Spouse/Partner Declaration

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) (“ FOIP”) to determine and verify the Applicant’s eligibility for financial
assistance, to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance
programs in accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student
Financial Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is
managed in accordance with FOIP.

The personal information may be disclosed to:

• federal, provincial or territorial government departments or • any lending institution or credit bureau to verify any
agencies or educational institutions named in this Application, information the Applicant provided, to determine the eligibility
to verify information the Applicant provided, determine the of the Applicant for financial assistance and to administer
eligibility of the Applicant for financial assistance and to student financial assistance programs.
administer student financial assistance programs.
• the Applicant for the purposes of determining and verifying
• the federal government for use in research, statistical the Applicant’s eligibility for financial assistance.
analysis and evaluations related to student financial
assistance programs.
• Alberta Human Services to operate and administer financial
assistance programs, including your eligibility, and the
eligibility of the Applicant, for financial assistance.

If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll
free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Spouse/Partner Declaration
• I declare that my personal information included on this form is true and complete.

Signature of Spouse/Partner (if applicable) Today’s Date

Day Month Year
X
_ i _ l i l l i i i

Student Aid Alberta Mailing A ddress

(Faxed or scanned documents are not accepted. You must provide an original signature.)

STUDENT AID ALBERTA

PO BOX 28000 STN MAIN
EDMONTON AB T5J 4R4

Page 425
 Student Aid Alberta

Request to Cancel or Replace a

Part-time Canada Student Loan Agreement

If you did not receive and/or cash the part-time Canada Student Loan Agreement issued
to you, use this form to let us know. The Student Aid Alberta Service Centre is available
toll-free at 1-855-606-2096. Please contact us so we can help you complete this form
and fulfill your request. Student Aid Alberta is unable to provide you with a replacement
part-time Canada Student Loan Agreement without a completed form.
If you lost or never received your part-time Canada Student Loan Agreement, the
Student Aid Alberta Service Centre can provide you with the Agreement number
required on this form.
If you request Student Aid Alberta to reissue a new part-time Canada Student Loan
Agreement, your previous Loan Agreement will be cancelled as duplicates are not
possible.

Return the completed form to Student Aid Alberta:

MAIL: PO Box 28000 Stn Main

Edmonton AB T5J 4R4

COURIER: 7th Floor Mailroom, Sterling Place

9940 106 Street
Edmonton AB T5K 2V1

FAX: 780-643-9201

June 2014
Page 426
 Request to Cancel or
Student Aid Alberta Replace a Part-time Canada
Student Loan Agreement

Innovation and Advanced Education is collecting this personal information under the authority of section
33(c) of the Freedom of Information and Protection of Privacy Act (Alberta) as it relates directly to and is
necessary for cancelling or reissuing a Certificate of Eligibility and part-time Canada Student Loan
Agreement. The use and disclosure of your personal information is managed in accordance with the
Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions about the
collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at
1-855-606-2096 from anywhere in North America.

First and Last Name

Social Insurance Number

Please check one:

□ I am requesting Student Aid Alberta cancel and reissue the part-time Canada Student Loan
Agreement(s) listed below as they were lost, stolen, or never received.

□ I am requesting Student Aid Alberta cancel the part-time Canada Student Loan Agreement(s) listed
below.

Part-time Canada Student Loan Agreement

Number Amount

(Call 1-855-606-2096 to obtain this number)

By signing below, I confirm I have not cashed, nor will I cash, the part-time Canada Student Loan
Agreement(s) listed above. I understand that if I make a false or misleading statement, I may be denied
financial assistance, and/or be required to immediately repay all financial assistance received, and/or be
subject to criminal prosecution.

Signature Date

June 2014
Page 427
 Personal Pre-Authorized
y^db&rbcvJi Student Aid Alberta
Service Centre
Deposit and Payment Agreement
Complete this form and mail to the Student Aid Alberta Service Centre at the address below or fax to 1-866-236-2332.
The Student Aid Alberta Service Centre will administer any pre-authorized deposits and payments on behalf of the
Government of Alberta.
1. YOUR PERSONAL INFORMATION
First Name:.

Last Name:

Telephone Number: ( ) SIN: I------ ------ ------ II------ ------ ------

Alberta student loan number: (Soc a Insurance Number)

2. YOUR BANK ACCOUNT INFORMATION

Complete the information below. If you have a chequing account, please attach a void cheque. The account must be at a Canadian bank held in
your name solelyor jointly. If you need help completing the information, you may want to contact your bank.
Name of Financial Institution: ____________________________________________________________________________

Branch/Transit Number: Bank Number:

Account Number:
IMPORTANT: Please note that changes to your bank account need to be received at the Student Aid Alberta Service Centre five (5) business
days BEFORE your next Alberta student loan payment or deposit is due or they won't be effective until the following month.

3. PRE-AUTHORIZED DEPOSIT AGREEMENT

You, the Borrower, hereby authorize the Student Aid Alberta Service Centre to deposit the proceeds of your current or any
future Alberta Student Loan(s) as defined in the Master Student Financial Assistance Agreement into your Bank Account
identified above.
4. PRE-AUTHORIZED PAYMENTS (FOR LOANS IN REPAYMENT)
You, the Borrower, hereby authorize the Student Aid Alberta Service Centre to debit your bank account by the amount of
$ __________ , starting in / (insert month and year), in accordance with the terms of your Master Student
Financial Assistance Agreement. These payments will be withdrawn by the Student Aid Alberta Service Centre on behalf
of the Government of Alberta. Note: Payments will be withdrawn on the same day each month, until the loan has been paid
in full.
5. YOUR RIGHTS and OBLIGATIONS
You, the Borrower, have certain recourse rights if any deposit or payment does not comply with this Pre-Authorized
Deposit and Payment Agreement. You, the Borrower, may revoke your authorization at anytime by providing written
notice to the Student Aid Alberta Service Centre at least five (5) business days prior to your next scheduled Alberta
Student Loan deposit or payment. To obtain more information on your rights, please contact your financial institution, or
visit www.cdnpay.ca. You can also contact the Student Aid Alberta Service Centre in writing, by phone toll free at 1
855 606-2096 from anywhere in North America, 1 855 306-2240 (TTY for the hearing impaired), 800 2 529-9242
(outside North A m erica-add the appropriate International Access Code), or by fax at 1 866 236-2332.

Borrower’s Signature Today’s Date

Collection of this personal information by Innovation and Advanced Education is done under the authority of section 33(c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“ FOIP” ) to administer your Alberta Student Loan. The use and disclosure of your
personal information is managed in accordance with FOIP. If you have any questions about the collection, use or disclosure of this
information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America.

Student Aid Alberta Service Centre

P.O. Box 4050 • Mississauga, STN A • Mississauga, ON • L5A 4M9

E&OE AB-PAPPform(E)(vers 5.4)

Page 428
 Personal Pre-Authorized
y^db&rbcvJi Student Aid Alberta
Service Centre
Deposit and Payment Agreement
Complete this form and mail to the Student Aid Alberta Service Centre at the address below or fax to 1-866-236-2332.
The Student Aid Alberta Service Centre will administer any pre-authorized deposits and payments on behalf of the
Government of Alberta.
1. YOUR PERSONAL INFORMATION
First Name:.

Last Name:

Telephone Number: ( ) SIN: I------ ------ ------ II------ ------ ------

Alberta student loan number: (Soc a Insurance Number)

2. YOUR BANK ACCOUNT INFORMATION

Complete the information below. If you have a chequing account, please attach a void cheque. The account must be at a Canadian bank held in
your name solelyor jointly. If you need help completing the information, you may want to contact your bank.
Name of Financial Institution: ____________________________________________________________________________

Branch/Transit Number: Bank Number:

Account Number:
IMPORTANT: Please note that changes to your bank account need to be received at the Student Aid Alberta Service Centre five (5) business
days BEFORE your next Alberta student loan payment or deposit is due or they won't be effective until the following month.

3. PRE-AUTHORIZED DEPOSIT AGREEMENT_____________________________________

You, the Borrower, hereby authorize the Student Aid Alberta Service Centre to deposit the proceeds of your current or any
future Alberta Student Loan(s) as defined in the Master Student Financial Assistance Agreement into your Bank Account
identified above.
4. PRE-AUTHORIZED PAYMENTS (FOR LOANS IN REPAYMENT)
You, the Borrower, hereby authorize the Student Aid Alberta Service Centre to debit your bank account when payments
become due, in accordance with the terms of your Master Student Financial Assistance Agreement. These payments will
be withdrawn by the Student Aid Alberta Service Centre on behalf of the Government of Alberta. Note: Payments will be
withdrawn on the same day each month, until the loan has been paid in full.

You, the Borrower, hereby authorize a change to the amount of the monthly debit to your bank account to a monthly
Davment amount of $ startina in / (MM/YY) (insert month and year).

5. YOUR RIGHTS and OBLIGATIONS

You, the Borrower, have certain recourse rights if any deposit or payment does not comply with this Pre-Authorized
Deposit and Payment Agreement. You, the Borrower, may revoke your authorization at anytime by providing written or
verbal notice to the Student Aid Alberta Service Centre at least five (5) business days prior to your next scheduled
Alberta Student Loan deposit or payment. To obtain more information on your rights, please contact your financial
institution, or visit www.cdnpay.ca. You can also contact the Student Aid Alberta Service Centre in writing, by phone
toll free at 1 855 606-2096 from anywhere in North America, 1 855 306-2240 (TTY for the hearing impaired), 800 2
529-9242 (outside North America - add the appropriate International Access Code), or by fax at 1 866 236-2332.

Borrower’s Signature Today’s Date

Collection of this personal information by Innovation and Advanced Education is done under the authority of section 33(c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“ FOIP” ) to administer your Alberta Student Loan. The use and disclosure of your
personal information is managed in accordance with FOIP. If you have any questions about the collection, use or disclosure of this
information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America.

Student Aid Alberta Service Centre

P.O. Box 4050 • Mississauga, STN A • Mississauga, ON • L5A 4M9
Page 429
E&OE AB-PAPPform(E)(vers 5.3)
Persons Case
Scholarship

/ d i b e r t A m

Page 430
 PERSONS CASE SCHOLARSHIP
The “Persons Case” Scholarship was established in 1979 to commemorate the 50th anniversary of the “Persons Case”. The
scholarship is jointly administered by Alberta Innovation and Advanced Education and Alberta Human Services. The scholarship
honours the efforts of five Alberta women: Emily Murphy, Louise McKinney, Nellie McClung, Irene Parlby, and Henrietta Muir
Edwards; who fought and won the right for the women of Canada to be officially deemed “persons” under the law.

Award Value - $1,000 to $5,000

Eligibility Criteria
Applicants must be:
• a Canadian Citizen or a Permanent Resident and be an Alberta resident, and
• a full-time student in the current academic year (August 1 to July 31) at an Alberta post-secondary institution approved
by Alberta Innovation and Advanced Education. Consideration will be given to undergraduate students studying out-of-
province, however, they must identify the special nature of the out-of-province program. Students pursuing graduate
studies out-of-province will be given full consideration.

Selection Procedure
The Selection Committee will consider an applicant’s program of studies, academic achievement, and personal essay.
Students whose studies will ultimately contribute to the advancement of women, or who are studying in fields where members of
their gender are traditionally few in number are encouraged to apply.
Students entering the second or subsequent year of their program and who were selected to receive a scholarship generally had a
GPA of 3.0 or greater. Approximately thirty to forty recipients are selected for a total budget of $100,000.

Application Procedure
Submit with the application:
• an official transcript of all post-secondary studies, and an essay outlining why the issues you are studying
arc important to you and how your studies, activities and community involvement contribute to the advancement of
women, and
• a curriculum vitae/resume including your volunteer experience, scholarships received and amount awarded.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
dcsignedto stimulate the pursuit of excellence by rewarding outstanding achievement and encouraging Albertans to achieve their fullest
potential.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB - T5K 2V1

Telephone: 780.427.8640
mail: scholarships@gov.ab.ca
Website: alis.aiberta.ca/scholarships

APPLICATION DEADLINE IS SEPTEMBER 30

Page 431
 PERSONS CASE SCHOLARSHIP

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under
the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the
collection of this information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta,T5K 2V1
Phone 780.427.8640.

PERSONAL INFORMATION
You may use the Learner Registry at www.education.gov.ab.ca to find your Alberta Student Number or to have one assigned.
Alberta Student Number (required for processin l) Social Insurance Number (required for processing)

Surname Given Name and Middle Initial

City/Town

Province Postal Code Area Code Telephone Number

CITIZENSHIP (check one) *ALBERTA RESIDENCY

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta (circle one)

___PERMANENT RESIDENT (Landed Immigrant) Y N Have you lived in Alberta all your life? (circle one)
Note: Include a photocopy of permanent resident card.
Visa students are not eligible. If no, since , | ,
month year

Gender (circle one) Birthdate (Dav, Month, Year) E-Mail Address

M F
____ 1____ ____ 1____ 1
____ 1____ 1____ 1____

*If your parents do not currently reside in Alberta AND you have not lived in Alberta all your life,
please include a letter explaining the time spent in Alberta as a non full-time student.

APPLICATION DEADLINE IS SEPTEMBER 30

Office Use Only

Revised: February 2014

Page 432
 EDUCATION INFORMATION

Which institution will you attend this fall? What program will you be enrolled in?

What year of study will you be enrolled in?

1st | 12nd I 3rd | 14th | | Other
What is the length of your program?__ ___
1 Yr. 2 Yrs. 3 Yrs. Q 4 Yrs. Q Other
What degree or diploma will you graduate with? When will you complete the program?

J ____ L
month year
What is your desired occupation?

Education Record
Please list the last three schools, colleges or universities that you attended.
(If you have attended more than three schools, you may include the information on a separate resume)

Period of Study Educational Institution

From To Name of Institution Program

ESSAY QUESTION
Use no more than a 1,000 words (include a word count); double spaced, with a font size of 12 and do not type on both sides of the
page.
The essay is a significant component o f the application and selection. It is, therefore, critical that you elaborate on the following:
*describe how your studies, activities and community involvement contribute to the advancement of women, and
provide details of the extent and level of your involvement in these areas (include a resume), and
*give a brief explanation why the program of study you chose is important to you.
If enrolled in a non-traditional program, please provide some detail on the program.

HELPFUL HINTS
Incomplete applications will not be submitted to the selection committe, therefore, to ensure your application is reviewed by the
selection committee make sure you have:
□ answered all questions,
□ included your essay,
□ attached a resume, and
□ attached original transcripts from all post-secondary studies.

Notification of the results may be expected in December.

Page 433
 DECLARATION OF APPLICANT

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and eomplete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office o f Alberta Scholarship Programs in writing if I
withdraw from full-time studies before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my post-secondary academic progress and
enrolment status may be released and exchanged by and between Alberta Scholarship
Programs and the educational institution for the purpose of determining my eligibility
for a scholarship;
b. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Scholarship Programs, and for the use in research and
statistical analysis in program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want
to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Please indicate how you heard about the Persons Case Scholarship (check more than one if applicable):

ALIS website □ School/College counsellor at

Scholarship Brochure □ Friends

0 Family □ Other __________________

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships
 Program Compliance & Investigations - Telephone Notes

Student Name: S.I.N.:

Telephone: Display:

Contact Instituted by: (check one) □ SFB by: or □ Student / Representative

Conversation with: (select one)

□ Student
□Other Name:

Date: Time: Taken By:

Details:

□ Follow-up Required

Page 435
 POWER OF ATTORNEY
For Student Aid Alberta
Student Aid Alberta
Instruction Sheet for Students
What is Power of Attorney?
When you assign a P o w e r o f A tto rn e y you authorize someone else to have access to or to act on your behalf in
regard to your personal information with Student Aid Alberta and/or on matters concerning your student aid
including all Alberta student loans cashed through the Student Aid Alberta Service Centre and grants made for
educational purposes. A Power of Attorney remains in effect for five years from the date you sign it or until you
revoke (cancel) it. You may want to assign a Power of Attorney if:
• you are studying out of • you are studying out of • you want someone else
country province to act on your behalf

Important points regarding a Power of Attorney

• For instructions regarding a Power of Attorney for Alberta student loans you cashed at a bank, talk to the
bank holding your loan.
• The person that you designate as your attorney under a Power of Attorney c a n n o t sign for you on a
paper Application for Student Financial Assistance, or on the Master Student Financial Assistance
Agreement - Alberta. Student Aid Alberta requires an original signature from you on these documents.
• Student Aid Alberta strongly recommends that only the provincial government Power of Attorney form for
Alberta student aid be submitted. Power of Attorney forms from lawyers may be accepted, however,
please be aware that there may be delays in reviewing and processing these non-government forms
and/or there may be restrictions on the power granted with these other legal documents.

Key definitions to help you fill out the form correctly

W h o is th e " d o n o r " ? The "donor" is you, the student. You must be at least 18 years of age. If you are
physically unable to sign, another person may sign on your behalf at your direction, and in the presence of both
yourself and the witnesses. The designated attorney, or the spouse or adult interdependent partner of the
designated attorney cannot sign on your behalf. You must be mentally capable of understanding the nature and
effect of the Power of Attorney on the date it is signed.

W h o is th e " a tto r n e y " ? The "attorney" is the person you designate and authorize to act on your behalf and must
be at least 18 years of age at the time you execute the Power of Attorney. For example, if you designate and
authorize your father to act on your behalf, then your father is the "attorney". The actions of your “attorney” are
legally binding on you.

W h o is th e " w itn e s s " ? The "witness" can be anyone except for the following:
• A person under the age of 18 years of age;
• The person designated as your attorney;
• The spouse or adult interdependent partner of the person designated as your attorney;
• The person, or the spouse or adult interdependent partner of the person, signing the Power of Attorney
on your behalf if you are physically unable to sign the Power of Attorney; or
• You, your spouse or adult interdependent partner, your child or person treated as your child.

Easy steps to complete the Power of Attorney form

1) Print and read this form. If y o u a re s tu d y in g o u ts id e o f A lb e rta o r C anada , c o m p le te th e P o w e r o f
A tto rn e y fo rm b e fo re y o u le a ve A lb e rta .
2) Complete the donor’s name and address. (Your legal name and address.)
3) Complete the attorney’s name and address. (This is the person you want to designate and authorize to act
on your behalf.)
4) Plave the attorney sign the form and complete the Relationship of Attorney to the Donor line.
5) Sign the Power of Attorney form in the presence of two witnesses (see above restrictions on who can be a
witness).
6) Plave both witnesses sign and complete the Power of Attorney form, in your presence and each other’s
presence.
7) Make photocopies of the form and distribute as follows:
a) The original copy to your attorney to keep in a secure place
b) Keep one copy for your records
8) Submit the form to Student Aid Alberta:
• Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely
using e-Document Upload.
• Or mail to: Student Aid Alberta, PO Box 28000 Stn Main Edm AB T5J 4R4

Questions?
This Power of Attorney has been prepared for your convenience and the Government of Alberta makes no
representation whatsoever about the form, usability, or validity of this Power of Attorney. For general questions with
respect to the submission of this document, contact the Student Aid Alberta Service Centre toll free at
1-855-606-2096 from anywhere in North America.
If you have any questions about the use or effect of this document, you should seek the advice of a lawyer who can
advise you about the validity and the consequences of using this document.

July 2015
Page 436
 This Power of Attorney has been prepared for your convenience and the Government of Alberta
makes no representation whatsoever about the form, usability, or validity of this Power of Attorney.
If you have any questions about the use or effect of this document, you should seek the advice of a
lawyer who can advise you about the validity and the consequences of using this document.
Student Aid Alberta

POWER OF ATTORNEY
For Student Aid Alberta
This POWER OF ATTORNEY is given by me,
(Full legal name of the student, the “Donor")
o f__________________________________
(Address)
1. A ppointm e nt: I appoint
(Full legal name of the attorney, the ‘ Attorney")
o f_________________
(Address)
as my lawful attorney to do anything on my behalf that I may lawfully do by an attorney in respect of all student loans,
grants and other financial assistance (collectively the “Alberta Student Loans”) made available to me for educational
purposes by Her Majesty the Queen in right of Alberta as represented by the Minister of Innovation and Advanced
Education (“Student Aid Alberta”), but excluding the signing and submission of any Application for Student Financial
Assistance to Student Aid Alberta and also excluding the signing and submission of any Master Student Financial
Assistance Agreement - Alberta.
2. Personal Inform ation: I consent to the disclosure of my personal information by Student Aid Alberta to my Attorney for
use in relation to the exercise of my Attorney’s powers under this Power of Attorney.
3. Previous Power of A tto rn e y: This Power of Attorney does not revoke any Power of Attorney that I have previously
signed, except that this Power of Attorney shall solely govern over any matters in respect of the Alberta Student Loans.
Student Aid Alberta shall be entitled to rely solely upon this Power of Attorney.
4. T erm ination: This Power of Attorney shall terminate on the earlier of:
(a) five years after the date I have signed it, or
(b) upon Student Aid Alberta receiving written notice, together with such supporting documents as may be required by
Student Aid Alberta, of:
(i) my termination of this Power of Attorney,
(ii) my Attorney’s resignation, death, bankruptcy or mental incapacity or infirmity, or
(iii) my mental incapacity or infirmity.
I acknowledge that until this Power of Attorney is terminated in accordance with this section 4, all acts of my Attorney in
accordance with this Power of Attorney will be binding on me.
5. Representations and W arranties: I and my Attorney (by signing below) jointly and severally represent and warrant to
Student Aid Alberta that: (a) my Attorney and I are 18 years of age or older, and (b) my Attorney and I have the mental
capacity to understand the nature and effect of this Power of Attorney.
6. Indem nity: I and my Attorney (by signing below) jointly and severally indemnify and hold harmless Student Aid Alberta,
and its directors, officers, employees and agents, against any and all claims, losses, liabilities and expenses (including
legal costs on a solicitor and client basis) that Student Aid Alberta incurs in any way relating to its actions under, or in
reliance upon, this Power of Attorney.
7. A cceptance: This Power of Attorney is subject to the acceptance and approval of Student Aid Alberta or its agents.

This Document has been signed and delivered by the Donor (Student) named in this Power of Attorney in the presence of
tw o W itnesses:

_______________________________________________ Dated the_______day o f_______________ , 20________ .

Signature of Donor (Student) giving the Power of Attorney (in effect for five years from the date of Donor's signature unless
earlier terminated in accordance with section 4)

Signed by tw o W itnesses in the presence of the Donor (Student):

(For Witnessing Requirements, see “ Who is the ‘Witness’?” on the instruction sheet attached to this form)

By signing below, each Witness confirms that they are eligible witnesses as described in the attached instruction
sheet.
_____________________________________________ Dated the_______day o f__________________ , 20.
Signature of First W itness

Print full legal name and address of First Witness

_____________________________________________ Dated the_______day o f__________________ , 20.
Signature of Second W itness

Print full legal name and address of Second Witness

By signing below, the Attorney does hereby give to Student Aid Alberta the representations, warranties and indemnity set
out in paragraphs 5 and 6 above for good and valuable consideration, the receipt of which is hereby acknowledged.

___________________________________________ Dated the_________day o f________________ , 20_______.

Signature of A ttorney named in th is Power of Attorney
(cannot sign on behalf of Donor (Student))

Print full legal name and address of the Attorney

Relationship of Attorney named in this Power of Attorney to the Donor (Student)

July 2015
Page 437
 Prairie Baseball
Academy Scholarship

s S i

JVfy
V
1 / L i to / , ^ / y J
^ P n A i» » 5 * s e s * u . A« a» emv ♦ l / ' Q Ifc K /r l/v V J
Page 438
 PRAIRIE BASEBALL ACADEMY SCHOLARSHIP

The Prairie Baseball Academy Scholarship rewards the athletic and academic excellence of baseball players and provides an
incentive and means for these players to continue with their post-secondary education. Up to S40,000 in scholarships is available.

This scholarship is co-sponsored by the Alberta Heritage Scholarship Fund and the Prairie Baseball Academy.

Award Value $500 to $2,000

Eligibility Criteria

Applicant must:
a. be a Canadian citizen or a Permanent Resident and be an Alberta resident,
b. be a participant in the Prairie Baseball Academy,
c. be enrolled as a full-time student at a post-secondary institution in Alberta,
d. have achieved a grade point average of 2.0 on a 4.0 scale in the previous semester of study, and
e. be recommended by the Scholarship Committee of the Prairie Baseball Academy.

Selection Procedure

Application forms are available from the Prairie Baseball Academy and from Alberta Scholarship Programs. Each nomination must
include a current transcript and attachments outlining the applicant’s extra curricular activities and future goals.

The Committee will select recipients based on academic standing, community involvement and baseball achievements.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve their fullest potential.

Application Deadline is October 15

Page 439
 PRAIRIE BASEBALL ACADEMY SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
You may use the Learner Registry at www.education.gov.ab.ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M
_L J___ L
day month year
CITIZENSHIP (check one)
^ CANADIAN CITIZEN or
□ PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card Visa students are not eligible.
ALBERTA RESIDENCY
Have you lived in Alberta for the last 12 consecutive months as a non full-time
Do your parents currently live
student before attending school full-time? OR Have you attended a post-
in Alberta?
secondary institution full-time in Alberta for the last two consecutive semesters?
If you have answered “NO” to both “residency”
questions, please include a letter explaining your time spent in Alberta.

EDUCATIONAL RECORD (A current academic transcript must be included with this application)

NAME OK HIGH SCHOOL TOWN/CITY PROVINCE YEAR COMPLETED

NAME OK POST-SECONDARY INSTITUTION KROM TO PROGRAM

Have you previously received a Prairie Baseball Academy Scholarship? YES

□ N° □
If yes, when _________________________________________________

Office Use Only

Revised: March 2013

Page 440
 Baseball Record
Note: To be considered, players must be current members of the Prairie Baseball Academy,

a. List teams played for:

b. Statistical Record (past and current year)

c. Awards or distinctions received (Scholastic/Sports)

ON AN ATTACHED PAGE PLEASE PROVIDE THE FOLLOWING:

1. A short summary outlining your extra curricular activities within the community during the past few years. The statement should
be typed and no more than one page in length, and
2. A brief outline of your future plans/goals. Again this should be typed and no longer than one page.

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E T H A T :
a. a ll in fo rm a tio n p ro v id e d is tru e and co m p le te and I understand it is su bje ct to a ud it,
b. I w il l be a fu ll- tim e student at th e in s titu tio n nam ed fo r the p e rio d stated,
c. I w il l im m e d ia te ly n o tify the o ffic e o f A lb e rta S ch o la rsh ip Program s in w r it in g i f I w ith d ra w fro m fu ll- tim e studies b efo re
c o m p le tin g one sem ester o f studies.

I U N D ER STAN D A N D AG REE THAT:

a. m y personal in fo rm a tio n p e rta in in g to m y h ig h sch o o l acad e m ic re c o rd m a y be released and e xchanged b y and betw e e n A lb e rta E d u catio n and A lb e rta
S c h o la rsh ip P rogram s fo r the purpose o f d e te rm in in g m y e lig ib ilit y fo r a s c h ola rsh ip ,
b. m y personal in fo rm a tio n p e rta in in g to m y post-se con d ary academ ic e n ro lm e n t status m a y be released and exchanged b y and betw een A lb e rta S ch o la rsh ip
P ro gra m s and the e du ca tio na l in s titu tio n fo r the purpose o f d e te rm in in g m y e lig ib ilit y fo r a sc h o la rs h ip ,
c. m y personal in fo rm a tio n m a y be released and e xchanged b y and betw een A lb e rta S c h o la rs h ip P rogram s and a ny p ro v in c ia l g o v e rn m e n t d epartm ents, boards o r
in s titu tio n s to v e r ify th e in fo rm a tio n I have p ro v id e d to A lb e rta S c h o la rs h ip P rogram s and fo r the use in research and sta tis tic a l a na lysis in p ro g ra m e v a lu a tio n .

I U ND E R S TA N D A N D AG R E E THAT:
i f I re ce ive a s c h o la rsh ip m y name, aw a rd and c ity /to w n m a y be released p u b lic ly to p ro m o te th e p ro g ra m , h ow e ve r, th is is n ot a c rite rio n fo r e lig ib ility ,
and i f I d o n ot w a n t to be id e n tifie d I w il l co n ta ct A lb e rta S ch o la rs h ip Program s.

Signature of Applicant (in ink) Today’s Date (in ink)

This Section is to be Completed by the Prairie Baseball Academy

I hereby confirm the Prairie Baseball Academy acknowledges that this applicant is a member and meets all terms and conditions of
this scholarship.

Name of Official:________________________________________________ Position: __________________________________

Signature of Official: ____________________________________________

 The Alberta Apprenticeship
and Industry Training Board
FAMILY OF SCHOLARSHIPS

The Application
Deadline
Pre-Apprentice June 30, 2014
Scholarships

The Pre-Apprentice Scholarships are designed to encourage those

who have completed pre-trades training to continue and complete
their apprenticeship training.

APPLICATION 2014

Apprenticeship
and Industry
Training
Government
Page 442
To apply, complete these steps:

STEP 1: Make sure you are eligible.

You m ust:
• be a Canadian citizen or Permanent Resident, and a resident of Alberta as defined by Alberta Scholarship Programs,
• have successfully completed a pre-apprentice program that included at least four weeks (120 hours)
of trades-related instruction, not including any work experience component,
• be a registered Alberta apprentice or plan to register within 12 months,
• submit your completed grades or proof of successful program completion.

STEP 2: Fully complete the application form.

• Your application must be accompanied by a completed Employer Recommendation (form enclosed).
• Some scholarships require demonstration of financial need. If you would like to apply for these scholarships,
complete the enclosed form.
• Your application must be complete. Incomplete applications will be removed from the selection process.
• Eligibility details and an electronic version of this application form can be found at tradesecrets.alberta.ca.

Please note: An A lb e rta S tu d e n t N um ber (ASN) is mandatory to apply for

an Apprenticeship and Industry Training Scholarship. This applies to all applicants
regardless if you have previously attended school in Alberta or not.

If you do not know your ASN or need to have one assigned (if you moved to Alberta
from another province or country), visit the Learner Registry at education.alberta.ca or
call (780) 427-5318. Due to privacy issues, ASNs will not be given out over the phone.

STEP 3: Forms must be post-marked by June 30, 2014.

Faxes or E-mails will not be accepted.

Send your completed application to:

Pre-Apprentice Scholarships You will be notified of the
c/o Alberta Scholarship Programs status of your application
Box 28000 Station Main by November 1,2014.

Edmonton, Alberta T5J 4R4

If you have any questions about the Alberta Apprenticeship and Industry Training Scholarships, please
contact Alberta Scholarship Programs at (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000)
or e-mail scholarships@ gov.ab.ca.

Page 443
Application for Pre-Apprentice N76
Scholarship 2014
Incomplete applications will be deemed ineligible and will be removed from the selection process.
We are collecting personal information in this application under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act,
c. F-25, FISA 2000 to determine and verify your eligibility for a Pre-Apprentice Scholarship under the Alberta Fleritage Scholarship Act, c. A-24, RSA
2000 and for research and statistical purposes. If you have any questions about the collection of this information, you can contact the Director, Alberta
Scholarship Programs, 4th Floor, 9940 - 106 Street, Edmonton, Alberta, T5K 2V1 Phone: (780) 427-8640.

(Please p rin t legibly using blue o r black ink)

Alberta Student Number

Apprentice I.D. Number

{if applicable) {Trade No.) {Apprentice I.D.)

Gender DlVIale □ Female Birth date

(please check one) day m onth year

Last Name First Name

Mailing Address

City/Town Province Postal Code

Telephone Number

Email ------------

Pre-Apprentice Training Provider ________

Pre-Apprentice Training Program ________

Length of Pre-Apprentice Program: From To Number

day m onth year day m onth year of Hours

City/Town Telephone Number

Have you registered for your next period of apprenticeship technical training? (please check one) □ Yes □ No

If yes, where?

Continued on reverse

Page 444
The Pre-Apprentice Scholarship 2014 Application Deadline: June 30, 2014 Page 1
Tell Us About Yourself
To be considered fo r a scholarship you m ust include one o r tw o paragraphs telling us about yourself. Include
w h a t you enjoy a bout yo u r trade, w hy you are choosing a career in the trades and how th is scholarship w ill
I
benefit you. Feel free to use additional o r typ e w ritten sheets as required. Please w rite legibly o r attach a typed
description a bout yourself.
Your w ritte n c o m m e n ts are very im p o rta n t to yo u r evaluatio n fo r a sch o la rsh ip . j
I
I
I
____________________________________________________________________________________________________________ I
I
------------------------------------------------------------------------------------------------------------------------------------------------------------------- I

I
I
Residency
C itize n sh ip (please check) □ Canadian Citizen □ Permanent Resident
i
NOTE: If you are a Perm anent Resident, you m u st include a p h o to c o p y o f y o u r p erm anent resident ca rd o r im m igration long form.
Visa students are ineligible.

Have you lived in A lberta all y o u r life? (please check) □ y es □ |\|0 If no, since
day m onth year

I
Do yo u r parents live in A lberta? (please check) □ Yes □ No
I
I
I
i
Page 445
The Pre-Apprentice Scholarship 2014 Page 2
Employer N76
Recommendation
Pre-Apprentice Scholarship Application
Please type or print legibly.

NOTE TO APPLICANT: P rin t y o u r nam e and tra d e in th is s e c tio n before giving th is fo rm to yo u r

em ployer, supervisor, o r su p e rvisin g c e rtifie d tra d e sp e rso n .

Pre-Apprentice Training Provider _____________________________________________________________________

NOTE TO THE EMPLOYER OR PERSON AUTHORIZED ON BEHALF OF THE EMPLOYER TO COMPLETE THIS
FORM (SUPERVISOR OR SUPERVISING CERTIFIED TRADESPERSON):

Your assessment of this apprentice is an important component in the scholarship selection process and m ust be
submitted prior to June 30, 2014 for the apprentice to be considered for a scholarship.

The Pre-Apprentice Scholarships are designed to encourage those who have completed pre-trades training to continue
and complete their apprenticeship training.

Please c o m p le te the fo llo w in g in fo rm a tio n regarding th e applicant:

This a p p lic a n t has sp e n t a to ta l o f m onths w o rkin g in the trade w ith me.

1. In y o u r opinion, is th is individual deserving o f a P re-A pprentice S cholarship?

□ Yes □ No*

2. In y o u r opinion, does th is individual fo llo w safe w o rk practices?

□ Yes □ No*

3. W hy is th is apprentice an outstanding candidate fo r a Pre-Apprentice Scholarship?

Your written comments are also very important to the evaluation of this apprentice. Use additional sheets if necessary.
Please include comments on some of the following: punctuality, work relationships, attitude, attendance, willingness to
learn and/or representation of self, employer and jobsite.

'Please note: Applicants that receive a “No” for either questions 1 or 2 are NOT eligible for a scholarship.

Page 446
The Pre-Apprentice Scholarships 2014
Employer

TEAR HERE
Recommendation
Trade Name

Dates applicant employed with organization: From To OR □ check box if still employed
day m o n th ye ar day m o n th ye a r with the company

Full Organization Name

Address

City/Town Province Postal Code

Telephone

Email

Name of person completing this form (please print)

Position of person completing this form: Employer □ Supervisor □ Certified Tradesperson □

Signature __________________________________________________________________ Date

day m o n th year

This form may be returned to the applicant to be mailed with their completed scholarship application
OR mailed directly to the following address:

Pre-Apprentice Scholarships
c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Telephone: (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000)

Please complete and sign this two-page Employer

Recommendation form and submit it before June 30, 2014.

Page 447
The Pre-Apprentice Scholarships 2014
 Financial Information (Completion of this section is optional)
This section does not apply to me. □ (check)

There are some scholarships where financial need is a criteria. If you wish to be considered for a scholarship
where financial need is a criteria, you must complete this section. If you choose not to complete this section, you
will still be considered for those scholarships without a financial need component.

Marital status: _______________________________ Number of dependents under 18 years of age: ______

Will you require an additional residence during technical training? (check) □ Yes Q No

Number of weeks of technical training __________________________

E x p e n s e s w h ile a tte n d in g t e c h n ic a l tr a in in g In c o m e w h ile a tte n d in g te c h n ic a l tr a in in g

(basic living expenses incurred for the duration of your (actual income for the duration of your technical
technical training; for example if technical training is 8 training; for example if technical training is 8 weeks
weeks long, determine expenses for 8 weeks) long, determine income for 8 weeks)

Rent/Mortgage of primary residence Employment Insurance Benefits *

(see note below)
Rent of second residence while
attending technical training (*if applicable) Wages/Salary after deductions
Utilities (heating, water, power, phone) Partner’s income after deductions
Food Grants/Bursaries
Transportation (gas, bus pass, parking) Alimony and/or Child Maintenance
Child Care/Babysitting/ Government Assistance
Child Maintenance Workers’ Compensation Benefits
Medical costs not covered by insurance Other income
Miscellaneous Total Income B
Total Expenses A

Total Need [Expenses (A) - Income (B]):

* IMPORTANT NOTE: Either the amount of your Employment Insurance (El) Benefits or an explanation of why you do not
qualify for El must be included. If an explanation is not provided the selection committee will assume you are receiving
maximum El Benefits.

Explain any exception al o r a d d itio n a l expenses you w o u ld like to bring to th e selection c o m m itte e ’s attention.

Page 448
The Pre-Apprentice Scholarships 2014 Page 3
 Aboriginal Scholarships
Some scholarships are designated for apprentices of Aboriginal descent. If you are Aboriginal and wish to be considered for one of
these scholarships, you must complete this section. If you choose not to complete this section, your application will still be considered
for those scholarships not specific to Aboriginal apprentices.

Aboriginal, as defined by the Canadian Constitution: “Aboriginal peoples of Canada” includes the Indian, Inuit and Metis peoples of Canada.
Are you of Aboriginal descent? (check) □ Yes □ No
If yes, please complete the following. Are you:

□ Indian: Which First Nation? _____________________________________________________________________________________

□ Metis: Which Metis Settlement or Zone?__________________________________________________________________________

□ Inuit: Where were you b o rn ? _____________________________________________________________________________________

NOTE: Applicants selected to receive an Aboriginal scholarship may be required to provide documentation verifying their status as an Aboriginal person.

Declaration and Authorization

I have read the instructions and hereby make an application for a RAP/CTS Scholarship.

I DECLARE: • Alberta Innovation and Advanced Education to provide my

• I have answered all the questions applicable to me and all
the information is true and complete and subject to audit.
• I plan to continue as an apprentice in my trade.
• I will notify the office of Alberta Scholarship Programs if I
withdraw from my apprenticeship program before
completion.
I AUTHORIZE:
• Alberta Scholarship Programs to request and receive my
marks and other information about my apprenticeship
program such as name of the institution I am attending and
my period of technical training, from Alberta Apprenticeship
and Industry Training for the purpose of determining my
eligibility for a scholarship. I also authorize Alberta
Apprenticeship and Industry Training to disclose this
information to Alberta Scholarship Programs.
• Alberta Scholarship Programs to request and receive from
the post-secondary institution I am attending, information
pertaining to my enrollment status for the purpose of
determining my eligibility for a scholarship. I also authorize
my post-secondary institution to disclose this information to
Alberta Scholarship Programs.
information to other funding agencies in Canada such as
non-profit organizations, industry associations, private
donors, municipal, provincial or federal governments, so that
I may be considered for any other apprenticeship
scholarships for which I may be eligible, in which case all the
information, consents, authorizations and declarations made
in this application apply to any such other apprenticeship
scholarship for which I may be considered.
If I am awarded a scholarship, I A U TH O R IZE:
• Alberta Innovation and Advanced Education, or its
representative, to publish my name, city/town, name of
employer, trade, pre-apprentice training program, institution,
name of scholarship awarded and photograph for publicity
purposes,
• Alberta Innovation and Advanced Education to provide my
name and contact information, trade, pre-apprentice training
program and the name of my employer, to the sponsor of my
scholarship, to any agency wishing to recognize the award,
to local MLA offices and to any interested media wishing to
contact me for the purpose of an interview.

SIGNATURE OF APPLICANT
day m o n th year
PRINT NAME ___________

Selection
A committee made up of members of the Alberta Apprenticeship and Industry Training Board will select recipients. Recipients will be
selected based on employer recommendation, demonstration of financial need and personal description. You will be notified of the
status of your application by November 1,2014. Apprentices will only be selected for a maximum of one scholarship each year within
the Alberta Apprenticeship and Industry Training Board Family of Scholarships.

Page 449
The Pre-Apprentice Scholarships 2014 Page 4
 Scholarship Donors
CLAC (2)
Major contributors from the private sector are able to
name their scholarship. Ferguson Glass Western Ltd.
Lehigh Inland Cement Ltd.

These scholarship donors are listed here. Merit Contractors Association (2)
Stollery Charitable Foundation (5)

Double check your application! Have you:

□ answered all of the questions and checked all of the

appropriate boxes in a neat and legible manner?

□ attached proof of successful completion of a Mail completed applications to:

pre-apprentice program?
Pre-Apprentice Scholarships
□ completed the residency section and if needed,
c/o Alberta Scholarship Programs
attached a photocopy of proof of residency?
Box 28000 Station Main
Edmonton, Alberta T5J 4R4
□ included the completed Employer
Recommendation form?
(or your employer can mail it separately)

□ signed the form?

Failure to do any of the above can result in your application being deemed ineligible. Please double check your
application to ensure it is complete.

Please Note

• You will be notified of the status of your application by November 1,2014.

• Only technical training that is part of an approved apprenticeship program will be recognized for payment of an
award. A list of approved programs can be found in the Technical Training Centre on tradesecrets.alberta.ca/learn-on-the-job.

• If you are challenging the technical training exam you will not be considered enrolled in technical training and therefore
will not be eligible to receive a scholarship.

• Scholarship cheques will be mailed to recipients when they have begun their next period of technical training.
Instructions will be sent to you in the scholarship recipient package, if you are selected.

• Recipients must qualify for and claim their scholarship within five years of being notified of their award.

• Complete eligibility details can be found at tradesecrets.alberta.ca.

If you have any questions about the Pre-Apprentice Scholarships, please contact Alberta Scholarship Programs at (780) 427-8640
(to be connected toll-free in Alberta, first dial 310-0000) or e-mail scholarships@gov.ab.ca.

Application Deadline: June 30, 2014 Page 450

 The Alberta Apprenticeship and Industry Training Board, in
partnership with industry and the Government of Alberta
created the Alberta Apprenticeship and Industry Training
Apprenticeship
Board Family of Scholarships.
and Industry
Training The Board’s Family of Scholarships includes the Alberta
Apprenticeship and Industry Training (AIT) Board
Scholarships, Top Apprentice Scholarships, Pre-Apprentice
Alberta Apprenticeship Scholarships and the Registered Apprenticeship Program
(RAP) Scholarships.
and Industry Training
Board The funds for the Pre-Apprentice scholarships are provided
by joint contributions from the private sector and the Alberta
Family of Heritage Scholarship Fund. A list of industry sponsors are
included in this application. Each Pre-Apprentice scholarship
Scholarships is valued at $1,000.

The Government of Alberta is committed to encouraging

and rewarding the excellence of Alberta students. To this
end, the government offers scholarships through the
Achievement Scholarship Program and the Alberta
Heritage Scholarship Fund.

Further information about Government of Alberta

scholarships can be obtained on the Internet at:
alis.alberta.ca/scholarships

Alberta or by contacting:
Alberta Scholarship Programs
Box 28000 Station Main
Scholarship Edmonton, Alberta T5J 4R4
Telephone (780) 427-8640 (to be connected
Program s toll-free in Alberta, first dial 310-0000)

scholarships@gov.ab.ca

Page 451
POST-SECONDARY PART TIME ASSESSMENT REPORT 14/15
Resident of Marital Number of Number of Number of Designated Designated Credit
Alberta Status Dependants Months Weeks (Provincial) (Federal) Check
Yes No Yes No Yes No Yes No
□ □ □ □ □ □ □ □

INCOME THRESHOLD TOTAL INCOME

F a m ily G ra n t L oan
S tu d e n t $
Size (F P T G /S G D C ) (P T C L /S P D G /F S E G /P T B )
1 $23,978 $46,283
S p o u s e /P a rtn e r $
2 $29,852 $64,796
3 $36,700 $77,664
TOTAL $
4 $44,557 $86,787
5 $50,537 $93,873
6 $56,996 $99,656
7 $63,457 $104,548

TYPES OF FUNDS AVAILABLE ELIGIBLE GRANT FUNDING PTCL REQUESTED

PTB S600/Semester All Students PROVINCIAL FEDERAL YES NO
PTCL
FPTG
$10,000 + Interest
$600/Semester
All Students
All Students
PTB FPTG
□ □
YES NO YES NO
SG D C
SPDG
$1,920/Loan Year
$2,000/Loan Year
Single Parcnt/Married
Disabled □ □ □ □ MAX PTCL
O/S LOAN
$ 10,000

FSEG $8,000/Loan Year Disabled AVAILABLE

SCHEDULE 4 ATTACHED? Y E sQ NO|

COST FEDERAL PROVINCIAL

TUITION/FEES

BOOKS/SUPPLIES

TRAVEL (0 for Correspondence) $50 X MONTHS

CHILD CARE (0 for Corresoondence) $75 X MONTHS X # OF DEPENDANTS

MISCELLANEOUS ($10 X # OF WEEKS X % OF COURSE LOAD DIVIDED BY 60%) %

TOTAL

CALCULATED NEED

REQUESTED NEED

IS S U E D A W A R D
Comments/Notes: (**A uditing courses are not funded**)
46 47 49
S G D C C A L C U L A T IO N
N e e d > ($ 4 0 0 0 - P T C L + $1200) S G D C 48
$ >$
P T B 31

PTCL

DATE: S C H 4:
TOTAL

Total Award SGDC Amount CL Amount GR Amount GR Amount ASCLK.

04 05 06 08 09 20
SN SN SN
FR. ST.
MSG MSG MSG SFB Authorization:

t:
22 SP. ST.
1
App ID

SF/PT Worksheet - June 2014

Page 452
 The Alberta Apprenticeship
and Industry Training Board
FAMILY OF SCHOLARSHIPS

Application
Deadline
The RAP/CTS June 30, 2014
Scholarships

The RAP/CTS Scholarships are designed to recognize the accomplishments

of Alberta high school students in the Registered Apprenticeship Program
(RAP) and the Career and Technology Studies (CTS) apprenticeship
pathways, and to encourage these students to continue and complete their
apprenticeship training.

APPLICATION 2014

Apprenticeship
and Industry
Training
Government
Page 453
To apply...
If you are a Registered Apprenticeship Program (RAP)
student, complete these steps:

STEP 1: Make sure you are eligible.

You m ust:
• be a Canadian citizen or Permanent Resident, and a resident of Alberta as defined by Alberta Scholarship Programs,
• have been registered as an Alberta apprentice in a trade while in high school,
• have completed at least 250 hours of on-the-job training and work experience in your trade while in high school,
• have completed the requirements for high school graduation in 2014 or earlier,
• be continuing in an approved regular apprenticeship program,
• have at least one period of technical training left to complete your apprenticeship.*
* Some exceptions may apply. Visit tradesecrets.alberta.ca for details.

STEP 2: Fully complete the application form.

• Your a p p lic a tio n m u st be a cco m p a n ie d by a c o m p le te d E m ployer R ecom m enda tion (form enclosed).
• Alberta Scholarship Programs will obtain your high school transcript and details of your apprenticeship program.
• Your application must be complete. Incomplete applications will be removed from the selection process.
• Eligibility details and an electronic version of this application form can be found at tradesecrets.alberta.ca.

Please note: An A lb e rta S tu d e n t N u m b e r (ASN) is now mandatory to apply for

an Apprenticeship and Industry Training Scholarship. This applies to all applicants
regardless if you have previously attended school in Alberta or not.

If you do not know your ASN or need to have one assigned (if you moved to Alberta
from another province or country), visit the Learner Registry at education.alberta.ca or
call (780) 427-5318. Due to privacy issues, ASNs will not be given out over the phone.

STEP 3: Forms must be post-marked by June 30, 2014.

Faxes or E-mails will not be accepted.

Send your completed application to:

RAP/CTS Scholarships
c/o Alberta Scholarship Programs
Box 28000 Station Main
You will be notified of the
Edmonton, Alberta T5J 4R4
status of your application
by November 1,2014.
If you have any q ue stion s a bo ut th e A lb erta A p p re n tice sh ip and In du stry Training
c o n ta c t A lb erta S cholarship Program s at (780) 4 2 7 -8 64 0 (to be co n n e cte d to ll-fre e in A lberta, firs t dial 310-0000)
or e-m ail s c h o la rs h ip s @ g o v .a b .c a .

Page 454
To apply...
If you are a Career and Technology Studies (CTS)
apprenticeship pathway student, complete these steps:

STEP 1: Make sure you are eligible.

You must:
• be a Canadian citizen or Permanent Resident, and a resident of Alberta as defined by Alberta Scholarship Programs,
• be a registered Alberta apprentice or plan to register within 12 months,
• have completed the requirements for high school graduation in 2014 or earlier,
• have completed one of the five apprenticeship pathways, (automotive service technician, carpenter, cook,
hairstylist, welder),
• have at least one period of technical training left to complete your apprenticeship.*
* Some exceptions may apply. Visit tradesecrets.alberta.ca for details.

STEP 2: Fully complete the application form.

• Your application must be accompanied by a certified copy of your Record of Courses Completed form
provided by your supervising teacher. This form must be completed and signed by your teacher, principal,
journeyperson instructor AND local Apprenticeship and Industry Training office.
• Alberta Scholarship Programs will obtain your high school transcript.
• Your application must be complete. Incomplete applications will be removed from the selection process.
• Eligibility details and an electronic version of this application form can be found at tradesecrets.alberta.ca.

Please note: An Alberta Student Number (ASN) is mandatory to apply for

an Apprenticeship and Industry Training Scholarship. This applies to all applicants
regardless if you have previously attended school in Alberta or not.

If you do not know your ASN or need to have one assigned (if you moved to Alberta
from another province or country), visit the Learner Registry at education.alberta.ca or
call (780) 427-5318. Due to privacy issues, ASNs will not be given out over the phone.

STEP 3: Forms must be post-marked by June 30, 2014.

Faxes or E-mails will not be accepted.

Send your completed application to:

RAP/CTS Scholarships
You will be notified of the
c/o Alberta Scholarship Programs
status of your application
Box 28000 Station Main by November 1,2014.
Edmonton, Alberta T5J 4R4

If you have any q ue stion s a bo ut th e A lb erta A p p re n tice sh ip and In du stry Training S cholarships, please c o n ta c t
A lb erta S cholarship P rogram s at (780) 4 27 -8 64 0 (to be co nn ecte d to ll-fre e in A lberta, firs t dial 310-0000)
or e-m ail s c h o la rs h ip s @ g o v .a b .c a .

Page 455
Alberta Apprenticeship and Industry Training Offices

Bonnyville
Floor 2 Provincial Building
4902 - 50 Avenue
Bonnyville, AB T9N 2J4
Phone: 780-826-6142
Calgary
Floor 2 Suite 200, Willow Park Centre
10325 Bonaventure Drive SE
Calgary, AB T2J 7E4
Fax: 780-826-1904 Phone: 403-297-6457 Fax: 403-297-3799

Edmonton Fort McMurray

Floor 7 Seventh Street Plaza, South Tower Floor 7 Provincial Building
10030 - 107 Street 9915 Franklin Avenue
Edmonton, AB T5J 4X7 Fort McMurray, AB T9H 2K4
Phone: 780-427-8517 Fax: 780-422-3734 Phone: 780-743-7150 Fax: 780-743-7492

Grande Prairie Hinton

Suite 100, Towne Centre Mall 564A Carmichael Lane
9845 - 99 Avenue Hinton, AB T7V 1S8
Grande Prairie, AB T8V 0R3
Phone: 780-538-5240 Fax: 780-833-4253 Phone: 780-865-8293 Fax: 780-865-8376

Lethbridge Medicine Hat

Floor 2 Room 280, Provincial Building 3021 Dunmore Road SE
200 5 - Avenue South Medicine Hat, AB T1B 2H2
Lethbridge, AB T1J 4C7
Phone: 403-381-5380 Fax: 403-381-5795 Phone: 403-525-3100 Fax: 403-525-3109

Peace River Red Deer

Midwest Building Floor 3 First Red Deer Place
9715- 100 Street 4911-51 Street
Peace River, AB T8S 1T4 Red Deer, AB T4N 6V4
Phone: 780-624-6529 Fax: 780-624-7188 Phone: 403-340-5151 Fax: 403-340-5153

Slave Lake Vermilion

Suite 109, Slave Lake Government Centre Floor 1 Provincial Building
101 - 3rd Street SW 4701 - 52 Street
Slave Lake, AB TOG 2A0 Vermilion, AB T9X 1J9
Phone: 780-849-7228 Fax: 780-849-7121 Phone: 780-853-8150 Fax: 780-853-8203

Toll-Free within Alberta, dial 310-0000 followed by 780-853-8150.

TDD/TTY: 427-9999 in Edmonton. In other locations call 1-800-232-7215.

Page 456
The RAP/CTS Scholarships 2014
Application for RAP/CTS N74
Scholarships 2014
Incom plete applications will be deem ed ineligible and will be rem oved from the selection process.
We are collecting personal information in this application under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act,
c. F-25, RSA 2000 to determine and verify your eligibility fora RAP/CTS Scholarship under the Alberta Heritage Scholarship Act, c. A-24, RSA 2000 and
for research and statistical purposes. If you have any questions about the collection of this information, you can contact the Director, Alberta Scholarship
Programs, 4th Floor, 9940 - 106 Street, Edmonton, Alberta, T5K 2V1 Phone: (780) 427-8640.

(Please print legibly using blue or black ink)

Please indicate which program you have completed: □ RAP □ CTS

Alberta Student Number

Apprentice I.D. Number

(Trade No.) (Apprentice I.D.)

Gender DlVIale □ Female Birth date

(please check one) day m onth year

Last Name First Name

Mailing Address

City/Town Province Postal Code

Telephone Number

Email ------------

Name of High School School Code

When did you/will you graduate from high school?

m onth

Number of hours of on-the-job training and work experience completed in your trade

If you have completed technical training prior to June 30, 2014, at which institution did you complete the technical training?

Have you registered for your next period of apprenticeship technical training? (please check one) □ Yes □ No

If yes, where?
Continued on reverse

Page 457
The RAP/CTS Scholarships 2013 Page 1
Residency
Citizenship (please check) □ Canadian Citizen □ Permanent Resident

NOTE: If you are a Perm anent Resident, yo u m u st include a p h o to c o p y o f yo u r perm anent resident ca rd o r im m igration long form.
Visa students are ineligible.

Have you lived in Alberta all your life? (please check) □ y es □ n0 If no, since
day m onth year

Do your parents live in Alberta? (please check) □ Yes □ No

Tell Us About Yourself

To be considered for a RAP/CTS Scholarship you must include one or two paragraphs telling us about yourself,
confirming your plans to continue in your apprenticeship program and why a career in the trades is a good fit
for you. Use additional sheets or attach typewritten pages as required. Please write legibly or attach a typed
description about yourself to the application.
Your written comments are very important to your evaluation for a scholarship.

Mail completed applications to: RAP/CTS Scholarships

c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

You will be notified of the status of your application by November 1, 2014.

Application Deadline: June 30, 2014

Page 458
Page 2
 Employer N74
TEAR HERE

Recommendation (for RAP students only)

RAP/CTS Scholarships
Please type or print legibly

NOTE TO RAP APPRENTICE: Print your name and trade in this section before giving this form to your
employer, supervisor, or supervising certified tradesperson.

Name of RAP Apprentice

RAP Apprentice I.D. Number

Trade Name ___________

NOTE TO THE EMPLOYER OR PERSON AUTHORIZED ON BEHALF OF THE EMPLOYER TO COMPLETE THIS
FORM (SUPERVISOR OR SUPERVISING CERTIFIED TRADESPERSON):

Your assessment of this apprentice is an important component in the scholarship selection process and must be
submitted prior to June 30, 2014 for the apprentice to be considered for a scholarship.

The RAP/CTS Scholarships are designed to recognize the accomplishments of Alberta high school students in the
Registered Apprenticeship Program (RAP) and the Careers and Technology Studies (CTS) apprenticeship pathways, and
to encourage these students to continue and complete their apprenticeship training.

Please complete the following information regarding the applicant:

This RAP apprentice has worked for me a total of hours in the trade.

1. In your opinion, is this individual deserving of an Alberta Apprenticeship and Industry Training Scholarship?

□ Yes □ No*

2. In your opinion, is this individual committed to safe work practices?

□ Yes □ No*

3. Why is this apprentice an outstanding candidate for a RAP/CTS Scholarship?

Your written comments are also very important to the evaluation of this apprentice. Use additional sheets if necessary.
Please include comments on some of the following: punctuality, work relationships, attitude, attendance, willingness to
learn and/or representation of self, employer and jobsite.

’ Please note: Applicants that receive a “No” for either questions 1 or 2 are NOT eligible for a scholarship.

Page 459
The RAP/CTS Scholarships 2014
i
Employer

TEAR HERE
Recommendation (for RAP students only)
Dates apprentice employed with company: From To OR □ check box if still employed
Please type or print legibly day m onth year day m onth year with the company

Full Company Name

Address

City/Town Province | Postal Code —

Telephone — —

Email

Name of person completing this form (please print)

Position of person completing this form: Employer □ Supervisor □ Certified Tradesperson □

Signature
day m o n th

This form may be returned to the RAP apprentice to be mailed with their completed scholarship application
OR mailed directly to the following address:

RAP/CTS Scholarships
c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Telephone: (780) 427-8640 (to be connected toll-free in Alberta, first dial 310-0000)

Please complete and sign this two-page Employer

Recommendation form and submit it before June 30, 2014.

Page 460
The RAP/CTS Scholarships 2014
 Declaration and Authorization
I have read the instructions and hereby make an application for a RAP/CTS Scholarship.

I DECLARE:
• I have answered all the questions applicable to me and all the information is true and complete and subject to audit.
• I plan to continue as an apprentice in my trade.
• I will notify the office of Alberta Scholarship Programs if I withdraw from my apprenticeship program before completion.

I AUTHORIZE:
• Alberta Scholarship Programs to request and receive my marks and other information about my apprenticeship program such as name
of the institution I am attending and my period of technical training, from Alberta Apprenticeship and Industry Training for the purpose of
determining my eligibility for a scholarship. I also authorize Alberta Apprenticeship and Industry Training to disclose this information to
Alberta Scholarship Programs.
Alberta Scholarship Programs to request and receive my high school transcripts from Alberta Education for the purpose of determining
my eligibility for a scholarship and I authorize Alberta Education to disclose this information.
• Alberta Scholarship Programs to request and receive from the post-secondary institution I am attending, information pertaining to
my enrollment status for the purpose of determining my eligibility for a scholarship. I also authorize my post-secondary institution to
disclose this information to Alberta Scholarship Programs.
• Alberta Scholarship Programs to review my application for consideration for an Alexander Rutherford Scholarship.
• Alberta Innovation and Advanced Education to provide my information to other funding agencies in Canada such as non-profit
organizations, industry associations, private donors, municipal, provincial or federal governments, so that I may be considered for
any other apprenticeship scholarships for which I may be eligible, in which case all the information, consents, authorizations and
declarations made in this application apply to any such other apprenticeship scholarship for which I may be considered.

If I am awarded a scholarship, I AUTHORIZE:

• Alberta Innovation and Advanced Education, or its representative, to publish my name, city/town, name of employer, high school,
trade, institution, name of scholarship awarded and photograph for publicity purposes.
Alberta Innovation and Advanced Education to provide my name and contact information, trade, year or period of training and the
name of my employer, to the sponsor of my scholarship, to any agency wishing to recognize the award, to local MLA offices and to any
interested media wishing to contact me for the purpose of an interview.

SIGNATURE OF APPLICANT
day m onth year
PRINT NAME ___________

Page 461
The RAP/CTS Scholarships 2014 Page 3
 Scholarship Donors
With industry support, the Alberta • Modern Beauty Supplies Inc. RAP Scholarship
Apprenticeship and Industry Training Board • Motor Dealers’ Association of Alberta RAP Scholarship
raised nearly $300,000 to establish the RAP • NOVA Chemicals Corporation RAP Scholarship
Scholarships. Founding donors ($10,000 or
• PCL Construction Group Inc. RAP Scholarship
more) were able to name a scholarship. In
• Shell Canada Ltd. RAP Scholarship
2012, the RAP scholarships were expanded to
include students who have completed Career • Sherwood Park Optimist Club RAP Scholarship
and Technology Studies (CTS) apprenticeship • Syncrude Canada Ltd. RAP Scholarship
pathways. Of the 500 RAP/CTS scholarships • TransCanada Pipelines Limited RAP scholarship
available each year, the following named
• Watson Family RAP Scholarship
scholarships were sponsored by major
• W. Kirkpatrick RAP Scholarship
contributors from the private sector.

For more information on the major private sector

• Alberta-Pacific Forest Industries Inc. RAP Scholarship contributors, visit tradesecrets.alberta.ca.
• Allan Askeland (Pacific Western Transportation) RAP
Scholarship
• Building Trades of Alberta/Construction Labour Relations Alberta Scholarship Programs
- An Alberta Association RAP Scholarship (2) The Government of Alberta is committed to encouraging
and rewarding the excellence of Alberta students. To this
• Calgary Foundation - Cadmus Fund RAP Scholarship (2)
end, the government offers scholarships through the
• CLAC RAP Scholarship
Achievement Scholarship Program and the Alberta
• Electrical Contractors Association of Alberta RAP Heritage Scholarship Fund.
Scholarship (2)
• Flint Energy Services Ltd. RAP Scholarship Further information about Government of Alberta
scholarships can be obtained on the Internet at:
• Fluor Constructors Canada Ltd. RAP Scholarship
alis.alberta.ca/scholarships
• International Brotherhood of Boilermakers and
Boilermaker Trust Fund RAP Scholarship or by contacting:
• Ironworkers Local 720 and Local 725/Alberta Ironworkers Alberta Scholarship Programs
and Apprenticeship Training Plan RAP Scholarship Alberta Scholarship Programs
Box 28000 Station Main
• Jacobs RAP Scholarship
Edmonton, Alberta T5J 4R4
• KBR (Canada) Ltd. RAP Scholarship
• Mechanical Contractors Association of Alberta RAP Telephone: (780) 427-8640 (to be connected toll-free in
Scholarship Alberta, first dial 310-0000)
• Merit Contractors Association RAP Scholarship scholarships@gov.ab.ca

Page 462
The RAP/CTS Scholarships 2014 Page 4
Double check your application! Have you:
□ answered all of the questions and checked all of the appropriate boxes in a neat and legible manner?

□ included your Alberta Student Number? (we use this to get your high school transcript)

□ included your apprentice I.D. number?

□ filled in the boxes on page 1 asking for number of hours of on-the-job training or work experience (if applicable)?

□ completed the residency section and if needed, attached a photocopy of proof of residency?

□ RAP applicants only: included the completed Employer Recommendation form? (or your employer can mail it separately)

□ CTS apprenticeship pathways applicants only: included a certified copy of your Record of Courses Completed form?

□ signed the application form?

Failure to do any of the above can result in your application being deemed ineligible. Please double check your
application to ensure it is complete.

Please Note

• Only technical training that is part of an approved apprenticeship program will be recognized for
payment of your award. A list of approved programs can be found in the Technical Training Centre on
tradesecrets.alberta.ca/learn-on-the-job

• If you have already received credit for one or more periods of technical training, please submit a copy of the
“successful completion” letter sent to you by Alberta Apprenticeship and Industry Training. Completion of the
Confirmation of Enrollment form is not necessary.

• If you are planning to challenge your next technical training exam you will not be considered enrolled in technical training
and therefore will not be eligible to apply for or receive a scholarship. (Does not apply to CTS apprenticeship pathway
students challenging their first period technical training exam).

• Scholarship cheques will be mailed to recipients when they have begun their next period of technical training.
Instructions will be sent to you in the scholarship recipient package, if you are selected.

• Recipients must qualify for and claim their scholarship within five years of being notified of the award.

• Complete eligibility details can be found at tradesecrets.alberta.ca

Apprentices will only be selected for a maximum of one scholarship each year within the Alberta Apprenticeship
and Industry Training Board Family of Scholarships.

Mail completed applications to:

RAP/CTS Scholarships
c/o Alberta Scholarship Programs
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Application Deadline: June 30, 2014

Page 463
 The Alberta Apprenticeship and Industry Training Board, in
partnership with industry and the Government of Alberta created
Apprenticeship the Alberta Apprenticeship and Industry Training Board Family
of Scholarships.
and Industry
Training The Board’s Family of Scholarships includes the Alberta
Apprenticeship and Industry Training (AIT) Board
Alberta Apprenticeship Scholarships, Top Apprentice Scholarships, Pre-Apprentice
Scholarships and the Registered Apprenticeship Program (RAP)/
and Industry Training Career and Technology Studies (CTS) Scholarships.

Board The funds for the RAP/CTS scholarships are provided by joint
Family of contributions from the private sector and the Alberta Heritage
Scholarship Fund. A list of industry sponsors are included in this
Scholarships application. Each RAP/CTS scholarship is valued at $1,000.

The Government of Alberta is committed to encouraging

and rewarding the excellence of Alberta students. To this
end, the government offers scholarships through the
Achievement Scholarship Program and the Alberta
Heritage Scholarship Fund.

Further information about Government of Alberta

scholarships can be obtained on the Internet at:
alis.alberta.ca/scholarships

Alberta or by contacting:
Alberta Scholarship Programs
Box 28000 Station Main
Scholarship Edmonton, Alberta T5J 4R4
Telephone (780) 427-8640 (to be connected
Program s toll-free in Alberta, first dial 310-0000)

scholarships@gov.ab.ca

Page 464
 ^4dherb&Ji Student Aid Alberta Reassessment Request
Program Compliance & Investigations
From:

Name: Q 2 Attending

To: Assessing

Name:

|__ | Current Funding Not Current

Reassessment Reason Project Type:

August 2012
Page 465
Calculated Need CL PL
60% CLE:

CL PL Grant Grant Grant Grant Total

Amount
Awarded
Current
Eligibility
Overpayment

Amount
Cancelled
Remaining O/P

ASCLK# App ID

I I I I I I____ I
SF/REAS Worksheet Nov 2014

Page 466
 Disability Grant for
yidb&rbfrji Disability Grants
PO Box 28000 Stn Main
Edmonton AB T5J 4R4
Services and Equipment
Reconciliation Worksheet
Student Aid Alberta

N am e:______________________________________ Social Insurance Number:

DEADLINE: This worksheet and all receipts must be returned by the end of your current study period. If you do
not provide receipts or return your unused funds, you will have a grant overaward that will reduce
your future eligibility for this grant.

INSTRUCTIONS:

1. Collect all your receipts and submit them at the same time, along with this worksheet.
2. Your receipts must indicate that you purchased approved services and/or equipment during the pre-study or
study period.
3. Submit only receipts that verify the amounts as paid or that show the method of payment (example:
Visa). Invoices alone cannot be accepted.
4. Write your name and Social Insurance Number (or Alberta Student Number) on all your receipts.
5. Complete the worksheet as in the example below. Submit your receipts with this worksheet.
6. If you have unused funds of less than $25, you do not need to repay the funds.
7. If you have unused funds of $25 or more, you must repay the funds. Make your cheque or money order
payable to: Government of Alberta.
8. Submit this worksheet and receipts:
• Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit
securely using e-Document Upload
• Or mail to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4
9. Mail your cheque or money order (for unused funds, if applicable) to:
Student Aid Alberta, Attention: Disability Grants, PO Box 28000 Stn Main, Edmonton AB T5J 4R4

EXAMPLE:

Cost Type $$ Awarded $$ Spent Receipt Attached? $$ To Be Returned

Zoomtext $700 $700 yes 0
Tutor $1200 $1000 yes $200

WORKSHEET:

Cost Type $$ Awarded $$ Spent Receipt Attached? $$ To Be Returned

Total Unused Funds = $

June 2015
Page 467
 Student A id Alberta
Mem orandum

FROM: Launa Lebeau DATE:

Director, Student Services Branch
TELEPHONE: 780-427-9820
Apprenticeship and Student Aid
REFERENCE:

TO: Andre Tremblay

Executive Director
Apprenticeship and Student Aid

SUBJECT
INSTITUTION
PROGRAM
ACADEMIC PERIOD(S)

AMOUNT OF FUNDING

___________________________________REQUEST FOR DECISION

CIRCUMSTANCES:

REASON FOR THE

REQUEST

RECOMMENDATION

Reviewed and approved by:

Hal Marcellin, Acting Manager, Program Compliance & Investigations Date

Launa Lebeau, Director, Student Services Branch Date

Page 468
1 | Pa ge Da IIa i r e
 Page 469
2 | Pa ge Da IIa i r e
 Student Aid Alberta Request Designation Review
Study Outside of Canada

To initiate a designation review, co m p lete and su bm it this form to S tudent Aid Alberta.
Please allow 1 to 4 w eeks to receive your designation review results via email.

My Personal Information:

Name:

Telephone:_________________________ Email:

School Information:

Name o f School:

Address:

Address Line2

City/Town: Province/State:

Postal Code/ZIP: C ountry:

Program o f Study:

Credential: EZI I I
Certificate — Diploma LJ Associate 1 1
Bachelor 1 1
Master/
Doctorate

S tart Date:
(dd/mm/yy)

C o rre s p o n d e n c e / 1— . ,— ■
E-Learning: |__ | Yes |___| No

Length o f Program : d l 1 Year or less mu mu mu Os

School Contact: 1
Name:

Position:

Telephone: Email:

S end d o c u m e n t: 1. Save completed form 2. Submit via email to: designationinquiry@gov.ab.ca

Page 470
 To initiate a designation review of a post-secondary educational institution outside of
Canada, complete this form and email to: designationinquiry@ gov.ab.ca

Student’s Name:

Phone: Email:

Name of Educational Institution:

Address:

Program of Study:

Enter program/session start and end dates for the 2014-15 school year:
Start: End:
What year of your program are you in? □ 1 n 2 n 3 a 4 D 5
Cost Estimates for above Dates of Study:
Tuition CAD$ Fees CAD$ Books & Supplies CAD$

Correspondence or E-Learning:

Institution Contact

Name:

Position:

Phone:

Email:
Page 471
S tu d e n t A id A lb e rta
 Request for Executive Review ^ 5/ ^ Q E R 2
Student Aid Alberta Form (Level 2) 2015/2016
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and Protection
of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service
Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

You can request an Executive Review of your student funding file if you are not satisfied with the result of your Request for Reconsideration.
Use this Level 2 form if you have already submitted a Request for Reconsideration Form (Level 1) and:
• you are not satisfied with the response
• your request was denied or you think the amount awarded is too low
• you want your circumstances reviewed at a higher level

Please provide as much information as possible to explain your reasons for requesting an Executive Review of your file in the space provided.
Be detailed, specific, and provide supporting documentation as required.
Deadline: Student Aid Alberta must receive your Request for Executive Review Form (Level 2) within 60 days from the date you received the
response to your Request for Reconsideration Form (Level 1). Student Aid Alberta allows for 14 days of mailing time. The 60 day deadline will
begin 14 days after the mailing date.
Processing time: It may take up to 60 days from the date of receipt for Student Aid Alberta to process your request.

Applicant's Personal Information

Alberta Student Number (mandatory)

(obtained from Alberta Transcript of High Award Reference Number
Social Insurance Number School Achievement) (Refer to your Student Award Letter)

M id d le
Last Name (current full legal name) First Name (current full legal name) Initial

I I I I I I I I I I I I I □
Apartment or Box Number Street Address

City/Town Prov/State Country Postal/Zip Code

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Mobile Number (format: 999-999-9999) to receive text messages Telephone Number (format: 999-999-9999)

± J__ I__ I__ I__ L

Email Address

Reason for Requesting an Executive Review - Attach Any Additional Documentation

07/16 A PP-TYPEIA APP-YEAR 2015/2016 APP-FORM-A For Office Use Only App ID

Page 1 Page 472

Reason for Requesting an Executive Review - Attach Any Additional Documentation

Applicant Declaration

This Request for Executive Review Form (Level 2) for Post-Secondary Studies, including any Schedules and documentation (“ Request
for Executive Review Form (Level 2)”), supplements, amends, and forms part of the Application for Financial Assistance that I
previously submitted to the Minister of Innovation and Advanced Education (“ Minister”) pursuant to the Student Financial Assistance
Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act (“Original Application”).
By submitting this Request for Executive Review Form (Level 2), I declare that all information provided in this Request for Executive
Review Form (Level 2) is true and complete, and I understand that the information that I provide is subject to review and assessment by
the Minister in accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student
Financial Assistance Act. I understand that this Request for Executive Review Form (Level 2) supplements, amends and forms part of
my Original Application.
I acknowledge that the declarations I provided in the Original Application and the declarations and consents I provided in the Master
Student Financial Assistance Agreement - Alberta and the Master Student Financial Assistance Agreement - Canada (see the
Completing your Master Student Financial Assistance Agreement information sheet at studentaid.alberta.ca) also apply to this Request
for Executive Review Form (Level 2) and to the personal information that I have provided in this form.
I understand that if I make a false or misleading statement in this Request for Executive Review Form (Level 2), fail to disclose
information or fail to notify the Minister of any changes to the information provided in this Request for Executive Review Form (Level 2),
it may result in one or more of the following: I may be denied financial assistance, be required to immediately repay all financial
assistance received, or be subject to criminal prosecution.

Upload or Mail Your Form

Send documents electronically* Mailing Address

1. Visit studentaid.alberta.ca STUDENT AID ALBERTA
2. Sign in via SFS Login PO BOX 28000 STN MAIN
3. Submit securely using e-Document Upload EDMONTON AB T5J 4R4
‘For assistance: e-Doc Upload FAQ

Page 2 Page 473

 Request for Ministerial Review ^ 5 /^ Q MR3
Student Aid Alberta Form (Level 3) 2015/2016
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and Protection
of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service
Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

You can request a Ministerial Review of your student funding file if you are not satisfied with the result of your Request for Executive
Review (Level 2).
Please provide as much information as possible to explain your reasons for requesting a Ministerial Review of your file in the space provided.
Be detailed, specific, and provide supporting documentation as required.
Deadline: Student Aid Alberta must receive your Request for Ministerial Review Form (Level 3) within 90 days from the date you received the
response to your Request for Executive Review Form (Level 2). Student Aid Alberta allows for 14 days of mailing time. The 90 day deadline will
begin 14 days after the mailing date.
Processing time: It may take up to 60 days from the date of receipt for Student Aid Alberta to process your request.

Applicant's Personal Information

Alberta Student Number (mandatory)

(obtained from Alberta Transcript of FUgh Award Reference Number
Social Insurance Number School Achievement) 'Refer to your Student Award Letter)

__ I__ I IMI I__ I IMI I__ I__ __ I__ I__ J__ I__ I__ I__ I__ J__ J__ __ I__ I__ I__ I__ I__ I__ I__
M id d le
Last Name (current full legal name) First Name (current full legal name) Initial

□
Apartment or Box Number Street Address

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
CityATown Prov/State Country Postal/Zip Code

I I I I I I I I I I I I I I I I
Mobile Number (format: 999-999-9999) to receive text messages Telephone Number (format: 999-999-9999)

I I I I I I I I I _L J__I__I__I__L
Email Address

Reason for Requesting a Ministerial Review - Attach Any Additional Documentation

07/16 A PP-TYPEIA APP-YEAR 2015/2016 APP-FORM-A For Office Use Only App ID

Page 1 Page 474

Reason for Requesting a Ministerial Review - Attach Any Additional Documentation

Applicant Declaration

This Request for Ministerial Review Form (Level 3) for Post-Secondary Studies, including any Schedules and documentation
(“ Request for Ministerial Review Form (Level 3)”), supplements, amends, and forms part of the Application for Financial Assistance
that I previously submitted to the Minister of Innovation and Advanced Education (“ Minister”) pursuant to the Student Financial
Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act (“Original Application”).
By submitting this Request for Ministerial Review Form (Level 3), I declare that all information provided in this Request for
Ministerial Review Form (Level 3) is true and complete, and I understand that the information that I provide is subject to review and
assessment by the Minister in accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the
Canada Student Financial Assistance Act. I understand that this Request for Ministerial Review Form (Level 3) supplements, amends
and forms part of my Original Application.
I acknowledge that the declarations I provided in the Original Application and the declarations and consents I provided in the Master
Student Financial Assistance Agreement - Alberta and the Master Student Financial Assistance Agreement - Canada (see the
Completing your Master Student Financial Assistance Agreement information sheet at studentaid.alberta.ca) also apply to this
Request for Ministerial Review Form (Level 3) and to the personal information that I have provided in this form.
I understand that if I make a false or misleading statement in this Request for Ministerial Review Form (Level 3), fail to disclose
information or fail to notify the Minister of any changes to the information provided in this Request for Ministerial Review Form
(Level 3), it may result in one or more of the following: I may be denied financial assistance, be required to immediately repay all
financial assistance received, or be subject to criminal prosecution.

Upload or Mail Your Form

Send documents electronically* Mailing Address

1. Visit studentaid.alberta.ca STUDENT AID ALBERTA
2. Sign in via SFS Login PO BOX 28000 STN MAIN
3. Submit securely using e-Document Upload EDMONTON AB T5J 4R4
'For assistance: e-Doc Upload FAQ

Page 2 Page 475

 Page A

Request for Reconsideration Form (Level 1)

1. (A) If your situation has changed, complete pages 1 and 2, and submit only the pages for the changes you require.
If you need to submit Schedules 1,2, 3, or 4, they are posted separately on studentaid.alberta.ca.
□ Change in Personal Information (legal name, marital status)
□ If your marital status has changed from Single to Married/Common Law, also complete Schedule 2
□ Change in Number of Dependent Children
□ Change in Full-Time or Part-Time Study Information
□ If you are Concurrently Enrolled, also complete Schedule 3 (Concurrently Enrolled
means you are simultaneously attending more than one school on a part-time basis.)
□ Change in Monthly Cost or Resource Information
□ Change in Parental Personal and Financial Information - complete Schedule 1
□ Change in Spouse/Partner Information - complete Schedule 2
□ I am now indicating that I have a Permanent Disability - complete Schedule 4

(B) If your situation has not changed but you did not receive enough money to cover expenses, or you did not receive any
funding, and you want your Application reassessed, complete pages 1 and 2 and provide an explanation for your request
in the space provided.

(C) If you have been reassessed and disagree with the result, complete pages 1 and 2 and provide an explanation
for your request in the space provided.

2. Submit your completed pages to Student Aid Alberta. Remember to include:

• Page A showing the changes you have selected
• pages 1 and 2 with your personal information and mandatory funding request question
• only the pages for each change you require
• acceptable supporting documentation as described on each page

Upload or Mail Your Form

Send documents electronically* Mailing Address

1. Visit studentaid.alberta.ca STUDENT AID ALBERTA
2. Sign in via SFS Login PO BOX 28000 STN MAIN
3. Submit securely using e-Document Upload EDMONTON AB T5J 4R4
‘For assistance: e-Doc Upload FAQ

Page 476
 J i Request for Reconsideration 15/16 RR1
Student Aid Alberta Form (Level 1) 2015/2016
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom of
Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for financial assistance, to administer
(including research, statistical analysis and evaluations) and to enforce student financial assistance programs in accordance with the Student
Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial Assistance Act, each as may be amended
from time to time. The use and disclosure of your personal information is managed in accordance with the Freedom of Information and Protection
of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service
Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Alberta Student Number (mandatory) Award Reference Number

Social Insurance Number 'obtained from Alberta Transcript of High School Achievement) (Refer to your Student Award Letter)

I I I I I I I I I I ___I___I___I___I___I___I___I___I___I___

Applicant's Personal Information

M id d le
Last Name (current full legal name) First Name (current full legal name) Initial

__ L_ I I I _L I I I _L I I I_L I J I __I I I I I I I I I I I I I I I I c
Apartment or Box Number Street Address

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
CityATown Prov/State Country Postal/Zip Code

I I I I I I I I I I I I I I I I
Mobile Number (format: 999-999-9999) to receive text messages Telephone Number (format: 999-999-9999)

I I I I I J__ I__ I__ L _L J__ I__ I__ I__ L

Email Address

Funding Request (mandatory)

Do you require additional funding If yes:

for your current period of study? □ I am requesting a specific amount $
OR
□ Yes □ No
□ I want the maximum amount I am eligible to receive

If yes, provide the reasons for your request for more funding in the space provided.

Reason for Requesting Additional Funding

07/16 A PP-TYPEIA APP-YEAR 2015/2016 APP-FORM-A For Office Use Only App ID

Page 1 Page 477

Reason for Requesting Additional Funding

Applicant Declaration

This Request for Reconsideration Form (Level 1) for Post-Secondary Studies, including any Schedules and documentation (“Request
for Reconsideration Form (Level 1)”), supplements, amends, and forms part of the Application for Financial Assistance that I previously
submitted to the Minister of Innovation and Advanced Education (“ Minister”) pursuant to the Student Financial Assistance Act (Alberta),
the Canada Student Loans Act and the Canada Student Financial Assistance Act (“Original Application”).
By submitting this Request for Reconsideration Form (Level 1), I declare that all information provided in this Request for
Reconsideration Form (Level 1) is true and complete, and I understand that the information that I provide is subject to review and
assessment by the Minister in accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and
the Canada Student Financial Assistance Act. I understand that this Request for Reconsideration Form (Level 1) supplements,
amends and forms part of my Original Application.
I acknowledge that the declarations I provided in the Original Application and the declarations and consents I provided in the
Master Student Financial Assistance Agreement - Alberta and the Master Student Financial Assistance Agreement - Canada (see the
Completing your Master Student Financial Assistance Agreement information sheet at studentaid.alberta.ca) also apply to this Request
for Reconsideration Form (Level 1) and to the personal information that I have provided in this form.
I understand that if I make a false or misleading statement in this Request for Reconsideration Form (Level 1), fail to disclose
information or fail to notify the Minister of any changes to the information provided in this Request for Reconsideration Form (Level 1),
it may result in one or more of the following: I may be denied financial assistance, be required to immediately repay all financial
assistance received, or be subject to criminal prosecution.

Page 2 Page 478

Change In Personal Information

Legal Name Change

If your name has changed, complete this section with your previous name(s) and attach a copy of one of the appropriate documents
listed below.

M id d le
Previous First Name in itia l Previous Last Name

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 □ 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Change in Marital Status

If your marital status has changed to married or common law, your spouse/partner must complete and sign a Schedule 2.
If your spouse’s/partner’s information has changed, they must provide the revised information on Schedule 2 and explain the
changes in the space provided.

Day Month Year

Date Marital Status Changed:
_I_ J___ L _I__
Marital Status Changed to:
□ Separated/Divorced/Widowed
□ Married
□ Common Law

Comments/Additional Information

Documentation Required

Circumstance Acceptable Documentation (provide copies - do not send originals)

Legal Name Change • Legal Name Change document • Driver’s license

• Marriage certificate • Passport
• Divorce/separation papers

Change in Marital Status • Marriage certificate • Driver’s license

• Divorce papers • Passport
• Letter stating date of separation

Page 479
Change in Dependent Children Information

If the number of dependent children has changed since you last applied, complete this section. Dependent children means those
children who are living with you and for whom you and/or your spouse/partner are legally responsible. Student Aid Alberta will
consider children over the age of 18 if they are permanently disabled or attending regular high school. If the child you are listing is not
your son or daughter (e.g. niece, nephew, grandchild) or if you have adopted a child, you must provide documentation confirming your
Legal Guardianship (see below).

Day Month Year

Date Changed:
! I I ! J___ I__

Last Name First Name Birthdate (day/month/year) Relationship to you

Monthly Child Care Costs (after subsidy)

Consideration may be given for child care/daycare costs exceeding $724/month/child with appropriate documentation.

Monthly Child Care Cost (after subsidy) $

Comments/Additional Information

Documentation Required

Circumstance Acceptable Documentation (provide copies - do not send originals)

Dependent Children over the age of 18 • If attending regular high school, provide the details in the space above
• If permanently disabled, provide medical documentation showing
your child requires special daily care

Legal Guardianship • Legal Guardianship papers verifying custody of the additional

dependent(s) you are now claiming

Additional Child Care Costs • Current receipt or statement from your child care provider (after subsidy)
OR
• Current receipt or statement from your child care provider showing
amount paid after subsidy

Page 480
Change In Full-Time or Part-Time Studies Information

Complete this section if you are changing programs and/or study start and end dates. You must attach documentation from your
school verifying the changes or your request will not be considered (see below).
There are some situations when you need to submit a new application instead of a Request for Reconsideration Form (Level 1).
If the situation(s) below applies to you, then submit a new Application for Financial Assistance:
• you are changing schools/campuses there is a break of 30 days or more between your school terms
• your new start date is more than 30 days past your original
start date

Program

1 1
Program Specialization/Major

I I I I I I I I I I I I I
Program Outcome
Are you enrolled in a correspondence/e-learning/distance study program? □ Yes □ No
□ Certificate
What year of this program will you be in? (check one)
□ Diploma
□ 1s' year or less □ 2nd year □ 3rd year □ 4lh or 5lh year
□ Degree
□ Degree - Masters Length of your program of studies (check one)
I i 1 year or less Q 2 years I 1 3 years Q 4 or 5 years
□ Degree - Doctoral
□ Journeyman Certificate

Dates I will attend school Start End

(these dates cannot Day Month Year Day Month Year
exceed 12 months)
___ I___ I___ i___ l___ I___ I___ I___ I___ i 1 i i 1 ± ___1___ 1___
Will you complete your program of study and receive your
post-secondary certificate, diploma, or degree by the session end date? □ Yes □ No

Educational Costs for Study Period

Tuition $ Books/Supplies/lnstruments $

Mandatory Fees (does not include

$ Computer Costs $
housing/residence costs)

Comments/Additional Information

Documentation Required

Circumstance Acceptable Documentation (provide copies - do not send originals)

Change in Full-time • Official documentation from your school indicating your program, specialization, program outcome,
or Part-time study program term dates, and a breakdown of your tuition, mandatory fees, and books/supplies.
information

Extension of study • Medical documentation AND confirmation from your school confirming that your study period end
end dates date has been extended. The maximum extension permitted for medical reasons is one (1) month.

f»a§e-481
Change in Costs and Resources - page 1
C o m p le te o n ly th e in fo rm a tio n th a t n e e d s to b e review e d.

While attending school, I will be living with: □ Parents □ Other

Costs

Your application has already been assessed for standard living costs (see studentaid.alberta.ca). If you are requesting additional
funding due to high costs, you must provide the appropriate documentation to be considered (see pages 2 and 3).

Date Costs Changed,

Monthly Costs While in School Monthly Amount
if applicable (day/month)

Rent/Mortgage $
I I I I
Utilities (power, water, phone, etc.) $
i I i i
Transportation (to get to and from school) $
I I I I
Medical (costs not covered by insurance) $
i I i i
Child Support Payments you make $
I I I I
Other (provide explanation on next page) $
i I i i
Total Monthly Costs $

Resources

Date Income Changed,

Monthly Resources While in School Monthly Amount
if applicable (day/month)

Wages/Salary (net income) $

I
Assistantships after deductions $
I
Stipends $
I
RESP and Voluntary Contributions from Parents $
I
Alimony and/or Child Support you receive $
I
Employment Insurance (El Benefits) $
I
Assured Income for the Severely Handicapped (AISH) $
I
Workers’ Compensation Benefits $
I
Aboriginal Affairs and Northern Development Canada/Band Funds $
I
Other Income (pensions, rental property, business) $
I
Total Monthly Resources $

(continued next page)

Page 482
Change in Costs and Resources - page 2
C o m p le te o n ly th e in fo rm a tio n th a t n e e d s to b e review e d.

Other Resources Available to Me

Savings you will have when you start school (include TFSAs) $

Assets (e.g. bonds, stocks, GICs, etc.) $

Registered Retirement Savings Plans (RRSPs) $

Other Resources List: $

Scholarships (e.g. Rutherford, Athletic, Louise McKinney, other) $

Comments/Additional Information

Page 483
Change in Costs and Resources - page 3

Documentation Required

Circumstance Acceptable Documentation (provide copies - do not send originals)

Requesting Tuition and Books Only • Submit a letter requesting tuition and books, or
If your resources exceed the costs Student Aid Alberta
• Call the Student Aid Alberta Service Centre
considers, you can request to receive funding to cover
the costs of your tuition and books.

Rent/Mortgage and Utilities • Copies of rent receipts or lease agreements

Consideration may be given for rent or mortgage
costs, property taxes, condo fees, and standard
utility payments.
• Mortgage agreements
• Copies of basic utility bills (e.g. power, natural gas, water, sewer,
garbage, phone) Cable, satellite, and internet are not considered
basic utilities.

Child Support/Alimony Payments • Proof of payment for the last four months, AND
made by you or your spouse/partner
• Maintenance Enforcement report, copy of court order, or a letter
Consideration may be given if you pay child
signed by your ex-spouse/partner that confirms the amount you
or spousal/partner support.
pay monthly

Transportation • Provide the distance it takes to travel from your residence

Additional travel costs may be considered for students to your school
when it is more economical to commute to school
• Receipts showing your basic vehicle insurance costs (PL7PD only)
rather than relocate.

Medical/Dental/Optical • Receipts and associated medical documentation.

Medical expenses that are not covered through
Alberta Health Care or your student health plan may
be considered.

Aboriginal Affairs and Northern Development • Provide confirmation from the band stating the monthly amount
Canada/Band Funds and whether the band will cover tuition, fees, and books.

Documentation Required for Other Exceptional Circumstances

Circumstance Acceptable Documentation (provide copies - do not send originals)

Additional Tuition, Fees, and Books • Provide official documentation from your educational institution
If your actual costs are higher than what your confirming your actual education costs.
educational institution has provided to Student
Aid Alberta, consideration can be made for your
high tuition.

Second Residence • Copies of rent receipts or lease agreements

If you are living apart from your spouse/partner
• Mortgage agreements
to attend school.
• Copies of basic utility bills (e.g. power, natural gas, water, sewer,
garbage, phone) Cable, satellite, and internet are not considered
basic utilities.

Student Loan Payments made by your • Provide a statement from the service provider confirming the
spouse/partner amount of the monthly payments.
If your spouse/partner is currently repaying a
government student loan, the cost of those payments
may be considered.

Other • Provide supporting documentation and/or receipts.

Other exceptional expenses may be considered.

Page 484
 Required Information for a
/ V A If) H F>(-) Box 28000 Stn Main
^ y < \, \ V < /X W kJ m Edmonton AB T5J 4R4 Correspondence/E-learning/
Student Aid Alberta Distance Study Program
Students should submit this form only when they receive a request to do so from Student Aid Alberta.

Student Name:____________________________ Program of Study:

Social Insurance Number:

To the Student
Under the Pan Canadian Designation Policy Framework there are specific requirements that must be met for
students requesting full-time funding when enrolled in a correspondence/e-learning/distance delivered program.
In order to determine whether you are eligible to receive full-time funding, please work with the Registrar’s Office
to complete this form. Then return the form via mail to the above address or fax it directly to (780) 422-4516.

To the School Official - please provide answers to the following questions:

1) Can students enrolled in this correspondence/e-learning/distance program be considered registered full­

time by your institution? □ Yes □ No
If yes, provide the credit/hour requirements for full-time enrollment: _____________________________

2) Are all of the courses within this correspondence/e-learning/distance program offered in a specified time
frame (with a definite start and end date)? □ Yes Q No

3) How are students monitored to ensure that academic progress and minimum full-time course loads are
being maintained?_______________________________________________________________________

4) What procedure does your institution have in place for those students who are not progressing?

5) Are students completing a minimum of 20 hours per week of student activity or participation?
□ Yes □ No

6) Are your residents eligible to apply for full-time financial assistance through the relevant student funding
authority? □ Yes □ No

7) Does the correspondence/e-learning/distance division of your institution operate under separate

administration and financial aid offices from the main institution? Q Y e s □ No

To the School Official - please complete

Signature of School Official Email address ‘ Required

Title/Position Date

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login

3. Submit securely using e-Document Upload September 2015
Or mail to: Student Aid Alberta, PO Box 28000 Stn Main, Edmonton AB T5J 4R4
Page 485
PLEASE NOTE: It is an offense under the Criminal Code of Canada to make a False or N a m e ! _________________________

Misleading statement. Any information provided on this form may be Social Insurance Number!_________________
used in criminal proceedings

RESUME TO BE COMPLETED AND RETURNED WITH YOUR INFORMATION REQUEST LETTER

FROM TO EMPLOYED or UNEMPLOYED ATTENDING SCHOOL RESIDENCE ADDRESS

Not Full- Part- Full- Part- (Include City and Province)
Month Year Month Year NAME & ADDRESS Emp Time Time Prov NAME & LOCATION Time Time Prov

Page 486
RESUME Ml Form.xls l:/Review/forms/resume Ml
 Student Aid Alberta

REVOCATION of Power of Attorney

For Student Aid Alberta
Instruction Sheet for Students

If y o u h a v e a s s ig n e d a P o w e r o f A tto rn e y a u th o riz in g s o m e o n e e ls e to h a v e a c c e s s to y o u r p e rs o n a l
in fo rm a tio n o r to a c t on y o u r b e h a lf o n m a tte rs c o n c e rn in g y o u r A lb e rta s tu d e n t a id , th e P o w e r o f
A tto rn e y re m a in s in e ffe c t fo r fiv e y e a rs fro m th e d a te y o u s ig n it, o r u n til it is te rm in a te d in a c c o rd a n c e
w ith c la u s e 4 o f th e P o w e r o f A tto rn e y . If y o u d e c id e to re v o k e (c a n c e l) y o u r P o w e r o f A tto rn e y yo u
m u s t g iv e w ritte n n o tic e to y o u r a p p o in te d a tto rn e y a n d In n o v a tio n a n d A d v a n c e d E d u c a tio n . If yo u
d o n o t a d v is e y o u r a tto rn e y th a t y o u h a v e re v o k e d th e P o w e r o f A tto rn e y , y o u m a y b e h e ld
re s p o n s ib le fo r th e a c ts o f y o u r a tto rn e y .

O n c e y o u h a v e re v o k e d th e P o w e r o f A tto rn e y a n d in fo rm e d y o u r a tto rn e y , th e a tto rn e y c a n no lo n g e r

re ly o n th e P o w e r o f A tto rn e y . If y o u r a tto rn e y c o n tin u e s to a c t o n y o u r b e h a lf, th e a tto rn e y m a y be
h e ld p e rs o n a lly re s p o n s ib le fo r th e a tto r n e y ’s a c ts .

Key definitions to help you fill out the form correctly

Who is the "donor"? T h e "d o n o r" is y o u , th e s tu d e n t. Y o u m u s t re v o k e th e P o w e r o f A tto rn e y in

w ritin g a n d y o u m u s t b e m e n ta lly c a p a b le o f u n d e rs ta n d in g th e n a tu re a n d e ffe c t o f th e re v o c a tio n on
th e d a te it is s ig n e d . If y o u a re p h y s ic a lly u n a b le to s ig n th e re v o c a tio n , a n o th e r p e rs o n m a y s ig n on
y o u r b e h a lf a t y o u r d ire c tio n , a n d in th e p re s e n c e o f b o th y o u rs e lf a n d th e w itn e s s e s . Y o u r a tto rn e y o r
th e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e a tto rn e y c a n n o t s ig n o n y o u r b e h a lf.

Who is the "attorney"? T h e "a tto rn e y " is th e p e rs o n y o u d e s ig n a te d a n d a u th o riz e d to a c t o n y o u r

b e h a lf.

Who is the "witness"? T h e "w itn e s s " c a n b e a n y o n e e x c e p t fo r th e fo llo w in g :

• A p e rs o n u n d e r th e a g e o f 18 y e a rs o f a g e ;
• T h e p e rs o n d e s ig n a te d as y o u r a tto rn e y ;
• T h e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e p e rs o n d e s ig n a te d a s y o u r a tto rn e y ;
• T h e p e rs o n , o r th e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e p e rs o n , s ig n in g th e
R e v o c a tio n o f P o w e r o f A tto rn e y o n y o u r b e h a lf if y o u a re p h y s ic a lly u n a b le to s ig n th e
R e v o c a tio n o f P o w e r o f A tto rn e y ; o r
• Y o u , y o u r s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r, y o u r c h ild o r p e rs o n tre a te d a s y o u r c h ild .

Easy steps to complete the Revocation of Power of Attorney form

1. P rin t a n d re a d th is fo rm .
2. C o m p le te th e d o n o r ’s n a m e a n d a d d re s s . (Y o u r le g a l n a m e a n d a d d re s s .)
3. C o m p le te th e a tto rn e y ’s n a m e a n d a d d re s s . (T h is is th e p e rs o n y o u d e s ig n a te d a n d
a u th o riz e d to a c t o n y o u r b e h a lf.)
4. S ig n th e R e v o c a tio n o f P o w e r o f A tto rn e y fo rm in th e p re s e n c e o f tw o w itn e s s e s (s e e a b o v e
re s tric tio n s o n w h o c a n b e a w itn e s s ).
5. H a v e b o th w itn e s s e s s ig n a n d c o m p le te th e R e v o c a tio n o f P o w e r o f A tto rn e y fo rm in y o u r
p re s e n c e a n d e a c h o th e r ’s p re s e n c e .
6. M a k e p h o to c o p ie s o f th e fo rm a n d d is trib u te a s fo llo w s :
a) th e o rig in a l c o p y to y o u r a tto rn e y
b) k e e p o n e c o p y fo r y o u r re c o rd s
7. S u b m it th e fo rm to S tu d e n t A id A lb e rta :
• S e n d d o c u m e n ts e le c tro n ic a lly : 1. V is it s tu d e n ta id .a lb e rta .c a 2. S ig n in v ia S F S L o g in
3. S u b m it s e c u re ly u s in g e -D o c u m e n t U p lo a d .
• O r m a il to : S tu d e n t A id A lb e rta , P O B o x 2 8 0 0 0 S tn M a in E d m A B T 5 J 4 R 4

Questions?
This Revocation of Power of Attorney has been prepared for your convenience and the Government of Alberta
makes no representation whatsoever about the form, usability, or validity of this Revocation of Power of
Attorney. For general questions with respect to submission of this document, contact the Student Aid Alberta
Service Centre toll free at 1-855-606-2096 from anywhere in North America.

If you have any questions about the use or effect of this document, you should seek the advice of a lawyer who
can advise you about the validity and the consequences of using this document.

July 2015

Page 487
 Student Aid Alberta

REVOCATION OF POWER OF ATTORNEY

For Student Aid Alberta
T h is REVOCATION OF POWER OF ATTORNEY is g iv e n by m e , ____________________________________
(Full legal name of the student, the "Donor”)

Of
(Address)

Revocation: I revoke th e P o w e r of A tto rn e y fo r S tu d e n t A id A lb e rta p re v io u s ly g iv e n by m e on the

d a y of , 20 , a p p o in tin a
(day) (month) (year)

of
(Full legal name of the attorney, the “Attorney”) (Address)

as m y law fu l a tto rn e y to d o a n y th in g on m y b e h a lf th a t I m a y la w fu lly d o by an a tto rn e y in re s p e c t of all

s tu d e n t lo a n s, g ra n ts a n d o th e r fin a n c ia l a s s is ta n c e m a d e a v a ila b le to m e fo r e d u c a tio n a l p u rp o s e s by
H e r M a je sty th e Q u e e n in rig h t o f A lb e rta as re p re s e n te d by th e M in is te r o f In n o va tio n a n d A d v a n c e d
E d u ca tio n (“S tu d e n t A id A lb e rta ”), b u t w h ic h e x c lu d e d th e s ig n in g a n d s u b m is s io n o f a n y A p p lic a tio n
fo r S tu d e n t F in a n cia l A s s is ta n c e to S tu d e n t A id A lb e rta a n d also e x c lu d e d th e s ig n in g and s u b m is s io n
o f a n y M a s te r S tu d e n t F in a n cia l A s s is ta n c e A g re e m e n t - A lb e rta .

2. Representations and W arranties: I re p re s e n t and w a rra n t to S tu d e n t A id A lb e rta th a t I h a ve th e

m e n ta l c a p a c ity to u n d e rs ta n d th e n a tu re a n d e ffe c t o f th is R e v o c a tio n of P o w e r of A tto rn e y .

3. Indem nity: I in d e m n ify a n d hold h a rm le s s S tu d e n t A id A lb e rta , a n d its d ire c to rs , o ffic e rs , e m p lo y e e s

a n d a g e n ts, a g a in s t a n y a n d all cla im s, lo s s e s , lia b ilitie s and e x p e n s e s (in c lu d in g legal c o s ts on a
s o lic ito r a n d c lie n t ba sis) th a t S tu d e n t A id A lb e rta in cu rs in a n y w a y re la tin g to its a c tio n s u n d e r, o r in
re lia n c e upon, th is R e v o c a tio n o f P o w e r o f A tto rn e y .

T h is d o c u m e n t has be e n signed and delivered by th e Donor (S tu d e n t) n a m e d in th is R e v o c a tio n of

P o w e r o f A tto rn e y in th e presence o f two Witnesses:

_______________________________________________________ D ated t h e ______ d a y o f _______________ , 20

Signature of Donor (Student) revoking the Power of Attorney

Signed by two Witnesses in th e presence o f th e Donor (S tu d e n t):

(For Witnessing Requirements, see “Who is the ‘Witness’?” on the instruction sheet attached to this form)

By signing below, each Witness confirms that they are eligible witnesses as described in the attached
instruction sheet.

Dated the day of , 20.

Signature of First Witness

Print full legal name and address of First Witness

Dated the day of 20

Signature of Second Witness

Print full legal name and address of Second Witness

T h is R e vo ca tio n o f P o w e r of A tto rn e y has b e e n p re p a re d fo r y o u r c o n v e n ie n c e a n d th e G o v e rn m e n t of

A lb e rta m a k e s no re p re s e n ta tio n w h a ts o e v e r a b o u t th e fo rm , u s a b ility , o r v a lid ity o f th is R e v o c a tio n of
P o w e r o f A tto rn e y . F o r g e n e ra l q u e s tio n s w ith re s p e c t to s u b m is s io n o f th is d o c u m e n t, c o n ta c t th e S tu d e n t
A id A lb e rta S e rv ic e C e n tre to ll fre e a t 1 -8 5 5 -6 0 6 -2 0 9 6 fro m a n y w h e re in N orth A m e ric a .

If you h a ve a n y q u e s tio n s a b o u t th e use o r e ffe c t o f th is d o c u m e n t, you s h o u ld s e e k th e a d v ic e of a la w y e r

w h o ca n a d v is e you a b o u t th e v a lid ity and th e c o n s e q u e n c e s of usin g th is d o c u m e n t.

July 2015

Page 488
 Student Aid Alberta

REVOCATION of Power of Attorney

For Student Aid Alberta
Instruction Sheet for Students

If y o u h a v e a s s ig n e d a P o w e r o f A tto rn e y a u th o riz in g s o m e o n e e ls e to h a v e a c c e s s to y o u r p e rs o n a l
in fo rm a tio n o r to a c t on y o u r b e h a lf o n m a tte rs c o n c e rn in g y o u r A lb e rta s tu d e n t a id , th e P o w e r o f
A tto rn e y re m a in s in e ffe c t fo r o n e y e a r fro m th e d a te y o u s ig n it, o r u n til it is te rm in a te d in a c c o rd a n c e
w ith c la u s e 4 o f th e P o w e r o f A tto rn e y . If y o u d e c id e to re v o k e (c a n c e l) y o u r P o w e r o f A tto rn e y yo u
m u s t g iv e w ritte n n o tic e to y o u r a p p o in te d a tto rn e y a n d In n o v a tio n a n d A d v a n c e d E d u c a tio n . If yo u
d o n o t a d v is e y o u r a tto rn e y th a t y o u h a v e re v o k e d th e P o w e r o f A tto rn e y , y o u m a y b e h e ld
re s p o n s ib le fo r th e a c ts o f y o u r a tto rn e y .

O n c e y o u h a v e re v o k e d th e P o w e r o f A tto rn e y a n d in fo rm e d y o u r a tto rn e y , th e a tto rn e y c a n no lo n g e r

re ly o n th e P o w e r o f A tto rn e y . If y o u r a tto rn e y c o n tin u e s to a c t o n y o u r b e h a lf, th e a tto rn e y m a y be
h e ld p e rs o n a lly re s p o n s ib le fo r th e a tto r n e y ’s a c ts .

Key definitions to help you fill out the form correctly

W ho is the "donor"? T h e "d o n o r" is y o u , th e s tu d e n t. Y o u m u s t re v o k e th e P o w e r o f A tto rn e y in

w ritin g a n d y o u m u s t b e m e n ta lly c a p a b le o f u n d e rs ta n d in g th e n a tu re a n d e ffe c t o f th e re v o c a tio n on
th e d a te it is s ig n e d . If y o u a re p h y s ic a lly u n a b le to s ig n th e re v o c a tio n , a n o th e r p e rs o n m a y s ig n on
y o u r b e h a lf a t y o u r d ire c tio n , a n d in th e p re s e n c e o f b o th y o u rs e lf a n d th e w itn e s s e s . Y o u r a tto rn e y o r
th e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e a tto rn e y c a n n o t s ig n o n y o u r b e h a lf.

W ho is the "attorney"? T h e "a tto rn e y " is th e p e rs o n y o u d e s ig n a te d a n d a u th o riz e d to a c t o n y o u r

b e h a lf.

W ho is the "w itness"? T h e "w itn e s s " c a n b e a n y o n e e x c e p t fo r th e fo llo w in g :

• A p e rs o n u n d e r th e a g e o f 18 y e a rs o f a g e ;
• T h e p e rs o n d e s ig n a te d as y o u r a tto rn e y ;
• T h e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e p e rs o n d e s ig n a te d a s y o u r a tto rn e y ;
• T h e p e rs o n , o r th e s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r o f th e p e rs o n , s ig n in g th e
R e v o c a tio n o f P o w e r o f A tto rn e y o n y o u r b e h a lf if y o u a re p h y s ic a lly u n a b le to s ig n th e
R e v o c a tio n o f P o w e r o f A tto rn e y ; o r
• Y o u , y o u r s p o u s e o r a d u lt in te rd e p e n d e n t p a rtn e r, y o u r c h ild o r p e rs o n tre a te d a s y o u r c h ild .

Easy steps to complete the Revocation of Power of Attorney form

1. P rin t o ff th is fo rm .
2. C o m p le te th e d o n o r ’s n a m e a n d a d d re s s . (Y o u r le g a l n a m e a n d a d d re s s .)
3. C o m p le te th e a tto rn e y ’s n a m e a n d a d d re s s . (T h is is th e p e rs o n y o u d e s ig n a te d a n d
a u th o riz e d to a c t o n y o u r b e h a lf.)
4. S ig n th e R e v o c a tio n o f P o w e r o f A tto rn e y fo rm in th e p re s e n c e o f tw o w itn e s s e s (s e e a b o v e
re s tric tio n s o n w h o c a n b e a w itn e s s ).
5. H a v e b o th w itn e s s e s s ig n a n d c o m p le te th e R e v o c a tio n o f P o w e r o f A tto rn e y fo rm in y o u r
p re s e n c e a n d e a c h o th e r ’s p re s e n c e .
6. M a k e p h o to c o p ie s o f th e fo rm a n d d is trib u te a s fo llo w s :
a) T h e o rig in a l c o p y to y o u r a tto rn e y
b) O n e c o p y to S tu d e n t A id A lb e rta , P O B o x 2 8 0 0 0 S tn M a in , E D M O N T O N A B T 5 J 4 R 4
c) K e e p o n e c o p y fo r y o u r re c o rd s .

Questions?

This Revocation of Power of Attorney has been prepared for your convenience and the Government
of Alberta makes no representation whatsoever about the form, usability, or validity of this Revocation
of Power of Attorney. For general questions with respect to submission of this document, contact the
Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America.

However, if you have any questions about the use or effect of this document, you should seek the
advice of a lawyer who can advise you about the validity and the consequences of using this
document.

June 2014

Page 489
 Student Aid Alberta

REVOCATION OF POWER OF ATTORNEY

For Student Aid Alberta
T h is REVOCATION OF POWER OF ATTORNEY is g iv e n by m e , ____________________________________
(Full legal name of the student, the "Donor”)

Of
(Address)

Revocation: I revoke th e P o w e r of A tto rn e y fo r S tu d e n t A id A lb e rta p re v io u s ly g iv e n by m e on the

d a y of , 20 , a o o o in tin a
(day) (month) (year)

of
(Full legal name of the attorney, the “Attorney”) (Address)

as m y law fu l a tto rn e y to d o a n y th in g on m y b e h a lf th a t I m a y la w fu lly d o by an a tto rn e y in re s p e c t o f all

s tu d e n t lo a n s, g ra n ts a n d o th e r fin a n c ia l a s s is ta n c e m a d e a v a ila b le to m e fo r e d u c a tio n a l p u rp o s e s by
H e r M a je sty th e Q u e e n in rig h t o f A lb e rta as re p re s e n te d by th e M in is te r o f In n o va tio n a n d A d v a n c e d
E d u ca tio n (“S tu d e n t A id A lb e rta ”), b u t w h ic h e x c lu d e d th e s ig n in g a n d s u b m is s io n o f a n y A p p lic a tio n
fo r S tu d e n t F in a n cia l A s s is ta n c e to S tu d e n t A id A lb e rta a n d also e x c lu d e d th e s ig n in g and s u b m is s io n
o f a n y M a s te r S tu d e n t F in a n cia l A s s is ta n c e A g re e m e n t - A lb e rta .

2. Representations and W arranties: I re p re s e n t and w a rra n t to S tu d e n t A id A lb e rta th a t I h a ve th e

m e n ta l c a p a c ity to u n d e rs ta n d th e n a tu re a n d e ffe c t o f th is R e v o c a tio n of P o w e r o f A tto rn e y .

3. Indem nity: I in d e m n ify a n d h old h a rm le s s S tu d e n t A id A lb e rta , a n d its d ire c to rs , o ffic e rs , e m p lo y e e s

a n d a g e n ts, a g a in s t a n y a n d all cla im s, lo s s e s , lia b ilitie s and e x p e n s e s (in c lu d in g legal c o s ts on a
s o lic ito r a n d c lie n t ba sis) th a t S tu d e n t A id A lb e rta in cu rs in a n y w a y re la tin g to its a c tio n s u n d e r, o r in
re lia n c e upon, th is R e v o c a tio n o f P o w e r of A tto rn e y .

T h is d o c u m e n t has be e n signed and delivered by th e Donor (S tu d e n t) n a m e d in th is R e v o c a tio n of

P o w e r o f A tto rn e y in th e presence o f two Witnesses:

_______________________________________________________ D ated t h e ______ d a y o f _______________ , 20_____ .

Signature of Donor (Student) revoking the Power of Attorney

Signed by two Witnesses in th e presence o f th e Donor (S tu d e n t):

(For Witnessing Requirements, see "Who is the ‘Witness’?” on the instruction sheet attached to this form)

By signing below, each Witness confirms that they are eligible witnesses as described in the attached
instruction sheet.

Dated t h e ________ day of 20

Signature of First Witness

Print full legal name and address of First Witness

Dated t h e ________ day of 20

Signature of Second Witness

Print full legal name and address of Second Witness

T h is R e vo ca tio n o f P o w e r of A tto rn e y has b e e n p re p a re d fo r y o u r c o n v e n ie n c e a n d th e G o v e rn m e n t of

A lb e rta m a k e s no re p re s e n ta tio n w h a ts o e v e r a b o u t th e fo rm , u s a b ility , o r v a lid ity o f th is R e v o c a tio n of
P o w e r o f A tto rn e y . F or g e n e ra l q u e s tio n s w ith re s p e c t to s u b m is s io n o f th is d o c u m e n t, c o n ta c t th e
S tu d e n t A id A lb e rta S e rvice C e n tre toll fre e at 1 -8 5 5 -6 0 6 -2 0 9 6 fro m a n y w h e re in N orth A m e ric a .

H o w e ve r, if you h a ve a n y q u e s tio n s a b o u t th e use or e ffe c t o f th is d o c u m e n t, you s h o u ld s e e k the

a d v ic e of a la w y e r w h o can a d v is e you a b o u t th e v a lid ity a n d th e c o n s e q u e n c e s of u s in g this
d o c u m e n t.

June 2014

Page 490
 R eset
Student Aid Alberta SAASC: Fwd when complete to Client Resolution Unit at cru@aov.ab.ca
Service Centre updated Oct 2015

REQUEST FOR RECONSIDERATION BY PHONE

Requested By: Student: Date:

Student ASN: SIN: App ID:

C H A N G E D E TE R M IN E D BY SAASC:

(select reason for change to student's assessment)

C om m ents / Instuctions to support change

CHANGE DETERMINED BY CRU:

□ (select reason for change to student's assessment)

C om m ents / Instuctions to support change

FIELD CHANGES / IMPACT TO ASSESSMENT:

(select reason)

| | Start (mm/d/yyyy): End (mmm/d/yyyy):

| | Childcare (per mo): $ Eff mm/yy: New Pgm? Y | | N

| | Marital status: (select if changing) Eff mm/yy: If Y, pgm:

PROMPTING QUESTIONS: |Q | Receivina
Receiving maintenance (add as Resource)
□ Moved? new address (notes) ED Paying maintenance (send req'd docs)
New total tuition:$
EDCustody arrangements (notes) EHName change (send req'd docs) New total fees: $
| | Living in study: (select if changing) Eff mm/yy: N e w to ta l b o o k s :$

| | Other Resource (specify): For T/F/B changes for in-province schools,

Amount:
Notes to support processing
$ Eff mm/yy:
check PAPRS maximums before submitting.
Costs above PAPRS maximum requires docs.
Pgm/date changes for student at PVI also
requires a change to enrolment contract. A
copy of this contract is required to change
funding. Refer student to school to discuss.

Any student switching institutions must be

withdrawn and reapply on a new application.

For office use only AppIO

Robert C. Carson
Memorial Bursary

J u stice and S olicitor

_ /4 i b G eneral
Page
 ROBERT C. CARSON MEMORIAL BURSARY

T he R obert C. C arson M em orial B ursary w as established by the M inistry o f Justice and Solicitor G eneral and
recognizes and rew ards academ ic achievem ent at the post-secondary level.

Award Value

Five bursaries o f $500 each. O ne aw ard w ill be allocated to each o f the follow ing institutions: Lethbridge
C ollege, M ount Royal U niversity, M acE w an U niversity, the U niversity o f A lberta and the U niversity o f
Calgary.

Eligibility Criteria

A nom inee m ust:

a. be a C anadian citizen or P erm anent R esident,

b. be a resident o f A lberta for at least three years,
c. be enrolled full-tim e in the Law E nforcem ent or C rim inal Justice D iplom a program at Lethbridge
C ollege, M ount Royal U niversity, or M acE w an U niversity, or the Law program at the U niversity o f
C algary o r the Law or C rim inology program at the U niversity o f A lberta, and
d. have com pleted one year o f the program and continuing into the second year.

In addition, preference w ill be given to aboriginal students w ho are not receiving sponsorship. H ow ever, all
non-sponsored students w ill be considered for the bursary.

Selection Procedure

Q ualifying students at each institution w ill be contacted by the Student A w ards O ffice to com plete an
application form . N om inations w ill then be forw arded to A lberta Scholarship P rogram s for review and final
approval.

Information on other awards administered by Alberta Scholarship Programs can be

obtained at:: alis.alberta.ca/scholarships

Nomination Deadline: September 30

Page 493
 ROBERT C. CARSON MEMORIAL BURSARY
W e are c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F re e d o m o f In fo rm a tio n a n d P ro te ctio n
o f P r iv a c y A c t ( F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r e lig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta
H e rita g e S c h o la r s h ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is
in fo n n a tio n , p le a s e c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th FI., 9 9 4 0 106 S treet, E d m o n to n , A B T 5 K 2V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information

A lb e rta S tu d e n t N u m b e r (go to www.education.gov.ab.ca to find your ASN or to obtain one) S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current full legal name) Please use upper and lower case. F ir s t N a m e a n d O n e In itia l (current full legal name)

M a ilin g A d d r e s s (Include Apt. or Box Number) C ity /T o w n

P re v io u s S u rn a m e
P r o v in c e C o u n tr y P o s ta l C o d e A rea C o d e T e le p h o n e N u m b e r

G e n d e r (circle one) B irth d a te E m a il A d d re s s

M F day month year
___ 1___ ___ 1___ ___ l _ J ___ 1___

CITIZENSHIP ( c h e c k one)

□ CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)

Note: Attach a photocopy of permanent resident card. Visa students arc not eligible.

ALBERTA RESIDENCY
D o e s o n e p a r e n t c u r r e n tly re s id e in A lb e r ta ? N H a v e y o u liv e d in A lb e r ta a ll y o u r life ? N

IF YOU HAVE ANSWERED “NO” TO BOTH QUESTIONS, I f n o , s in c e nth

PLEASE INCLUDE A LETTER EXPLAINING THE TIME YOU _L l i i
SPENT IN ALBERTA AS A NON FULL-TIME STUDENT.
Are you First Nations, Metis, or Inuit? Yes___ No ____
POST-SECONDARY STUDIES Are you being sponsored? Yes ___ No ___
(Sponsorship excludes student loan funding.)
N a m e o f In s titu tio n

N a m e o f P ro g ra m S ta rt D a te f o r P r o g r a m Y e a r o f P ro g r a m (first, second, third)

month | year
I I I \ I

Revised: April 2014

Page 494
 Declaration of Applicant

I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E TH A T:
a. a ll in f o rm a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a f u ll-tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e rio d s ta te d ,
c. I w ill im m e d ia te ly n o tify th e o f f ic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r itin g i f I w ith d r a w fr o m fu ll-tim e s tu d ie s b e fo r e
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D E R ST A N D A N D A G R E E THAT:
a. p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic r e c o r d m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n
A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility f o r a
s c h o la rs h ip ,
b. p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a
s c h o la rs h ip ,
c. m y p e rs o n a l in f o rm a tio n m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y p r o v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o rm a tio n 1 h a v e p r o v id e d to A lb e r ta S c h o la r s h ip P r o g r a m s ,
a n d f o r th e u s e in re s e a rc h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D E R ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is
is n o t a c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g ra m s .

Signature of Applicant Today’s Date (in ink)

To be Completed by the Nominating Institution

I hereby declare that this individual m eets all eligibility requirem ents for this bursary and is currently
enrolled as a full-tim e student.

Name of Institution Official:

Position: ______________

Signature of Official: ____

Phone Number: _________

Date:

Page 495
 Student Aid Alberta Routing Slip
^ 4 d b e * b f i. j i Student Aid Alberta Student’s Name:

Requested bv Date Social Insurance Number

Route To: (number in routing order)

__ | Program Payments and Revenue Support (PPRS)

□ Program Compliance and Investigations (All)

| Program Services (FS) / Executive (EX)

Q Filing (FI)

□ Heritage (HR)

] Loans Administration (GL)

□ Client
CM Resolution Unit

□ Assessing (AS)

__ | Missing Information (IR)

□ Instit/Program (NR)

□ Designation Services Unit

□ Processing (PS) □ Update Re-Enter Manual

Copy _ □ Name/SIN Changes

When all action is complete by all areas, ATTACH routing slip to file. AL-014 (2014)

Page 496
 Student Aid Alberta Routing Slip
^ 4 d b e * b f i. j i Student Aid Alberta Student’s Name:

Requested bv Date Social Insurance Number

Route To: (number in routing order)

__ | Program Payments and Revenue Support (PPRS)

□ Program Compliance and Investigations (All)

| Program Services (FS) / Executive (EX)

Q Filing (FI)

□ Scholarships

] Loans (PPRS)

□ Client
CM Resolution Unit

□ Assessing (AS)

__ | Missing Information (IR)

□ Instit/Program (NR)

□ Designation Services Unit

□ Processing (PS) □ Update Re-Enter Manual

Copy _ □ Name/SIN Changes

When all action is complete by all areas, ATTACH routing slip to file. AL-014 (2015)

Page 497
Confidential Parental* Personal and Financial Information 2014/2015 Schedule 1C
*This includes parents and step parents.
1 4 /1 5 S1C
Complete Schedule 1C if the applicant:
• is single and has been out of high school for less than 4 years, and Mail to:
• has not been available for full-time work for 2 or more years since Student Aid Alberta, PO Box 28000 Stn Main,
leaving high school Edmonton, AB T5J 4R4

Applicant’s Last Name Initials Social Insurance Number

PART B (OPTIONAL) - TO DETERMINE APPLICANT’S ELIGIBILITY FOR FEDERAL GRANTS AND LOANS,
AND ALBERTA LOW INCOME GRANT

Parents must complete Part B if you wish your child to be considered • Federal grant for Students with a Permanent Disability
for federal loans and the following grants: ($2,000 per academic year)
• Federal grant for Students from Low-Income Families • Federal grant for Services and Equipment for Students with
($250 per month of studies) a Permanent Disability (up to $8,000 per academic year)
• Federal grant for Students from Middle-Income Families • Alberta Low Income Grant ($120 per month of studies)
($100 per month of studies)
Parent 1 Last Name Parent 1 First Name

Parent 2 Last Name Parent 2 First Name

Is there a public transit system available from your home to the school your child is planning to attend? □ Yes Q No
(This does not include Greyhound, Red Arrow, etc.)

Family Size • include all of your children 0-17 years • include parent 1 & 2 as listed above
• include your children 18-22 (if they are full-time students) • do not include children over age of 22

Number of people in your family

Number of children attending post-secondary institutions in 2014/2015

Parental Total Income

Parent 1 Total income (Line 150 of 2013 Income Tax Return)

Parent 2 Total income (Line 150 of 2013 Income Tax Return)

Reduced Parental Total Income Fill in this section if either parent’s annual income from all sources (work, government or other)
is expected to be lower than Parental Total Income from line 150 above.

Parent 1 estimated yearly income

Parent 2 estimated yearly income

Innovation and Advanced Education is collecting this personal information
under the authority of sections 33(a) and (c) of the Freedom of Information
and Protection of Privacy Act (Alberta) (“ FOIP”) to determine and verify the
Applicant's eligibility for financial assistance, to administer (including research,
statistical analysis, and evaluations) and to enforce student financial assistance
programs in accordance with the Student Financial Assistance Act (Alberta), the
Canada Student Loans Act and the Canada Student Financial Assistance Act,
each as may be amended from time to time. The use and disclosure of your
personal information is managed in accordance with FOIP.
The personal information may be disclosed to:
• federal, provincial or territorial governments or agencies to verify any
information I have provided, to determine the eligibility of the Applicant for
financial assistance or to administer student financial assistance programs.
• the federal government for use in research, statistical analysis and
evaluations related to student financial assistance programs.
If you have any questions about the collection, use or disclosure
of this information, call the Student Aid Alberta Service Centre toll free at
1-855-606-2096 from anywhere in North America. You can also mail your
questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.
Parent Declaration
• I declare that the information given on this Schedule is true and complete.
• I understand that I am not co-signing for a loan.
• I understand this information will not be shared with the applicant.
• I understand that if I and the other parent choose to submit Schedule 1C
forms separately, the information will not be shared with the other parent.

Signature of Parent 1 Today’s Date

Day Month Year
X
I I I I __I I
Signature of Parent 2 Today’s Date
Day Month Year
X
___ I___ i i I i i i

Page 498
Confidential Parental* Personal and Financial Information 2015/2016 Schedule 1C
*This includes parents and step parents.
1 5 /1 6 S1C
Complete Schedule 1C if the applicant:
• is single and has been out of high school for less than 4 years, and Mail to:
• has not been available for full-time work for 2 or more years since Student Aid Alberta, PO Box 28000 Stn Main,
leaving high school Edmonton, AB T5J 4R4

Applicant’s Last Name Initials Social Insurance Number

Part B (Optional) - To Determine Applicant’s Eligibility for Federal Grants and Loans,
and Alberta Low Income Grant

Parents must complete Part B if you wish your child to be considered • Federal grant for Students with a Permanent Disability
for federal loans and the following grants: ($2,000 per academic year)
• Federal grant for Students from Low-Income Families • Federal grant for Services and Equipment for Students with
($250 per month of studies) a Permanent Disability (up to $8,000 per academic year)
• Federal grant for Students from Middle-Income Families • Alberta Low Income Grant ($250 per month of studies)
($100 per month of studies)
Parent 1 Last Name Parent 1 First Name

Parent 2 Last Name Parent 2 First Name

Is there a public transit system available from your home to the school your child is planning to attend? □ Yes Q No
(This does not include Greyhound, Red Arrow, etc.)

Family Size • include all of your children 0-17 years • include parent 1 & 2 as listed above
• include your children 18-22 (if they are full-time students) • do not include children over age of 22

Number of people in your family

Number of children attending post-secondary institutions in 2015/2016

Parental Total Income

Parent 1 Total income (Line 150 of 2014 Income Tax Return)

Parent 2 Total income (Line 150 of 2014 Income Tax Return)

Reduced Parental Total Income Fill in this section if either parent’s annual income from all sources (work, government or other)
is expected to be lower than Parental Total Income from line 150 above.

Parent 1 estimated yearly income

Parent 2 estimated yearly income

Innovation and Advanced Education is collecting this personal information
under the authority of sections 33(a) and (c) of the Freedom of Information
and Protection of Privacy Act (Alberta) (“ FOIP”) to determine and verify the
Applicant's eligibility for financial assistance, to administer (including research,
statistical analysis, and evaluations) and to enforce student financial assistance
programs in accordance with the Student Financial Assistance Act (Alberta), the
Canada Student Loans Act and the Canada Student Financial Assistance Act,
each as may be amended from time to time. The use and disclosure of your
personal information is managed in accordance with FOIP.
The personal information may be disclosed to:
• federal, provincial or territorial governments or agencies to verify any
information provided, to determine the eligibility of the Applicant for
financial assistance or to administer student financial assistance programs.
• the federal government for use in research, statistical analysis and
evaluations related to student financial assistance programs.
If you have any questions about the collection, use or disclosure
of this information, call the Student Aid Alberta Service Centre toll free at
1-855-606-2096 from anywhere in North America. You can also mail your
questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.
Parent Declaration
• I declare that the information given on this Schedule is true and complete.
• I understand that I am not co-signing for a loan.
• I understand this information will not be shared with the applicant.
• I understand that if I and the other parent choose to submit Schedule 1C
forms separately, the information will not be shared with the other parent.

Signature of Parent 1 Today’s Date

Day Month Year
X
I I I I __I I
Signature of Parent 2 Today’s Date
Day Month Year
X
___ I___ i i I i i i

Page 499
 Program Payments & Schedule J - Income and
^4dbetbfiji Revenue Support
PO Box 28000 Stn Main
Edmonton AB T5J 4R4
Expense Statement
Student Aid Alberta for Special Consideration
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for the Alberta
Special Consideration program and for the administration (including for research, statistical analysis and evaluations) and
enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta), as may be
amended from time to time. The use and disclosure of personal information is managed in accordance with the Freedom of
Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this
information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also
mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Debt Information Alberta Student Number I I I n

Alberta Student Loan Balance Owing: Grant Overpayment Balance Owing:
$ $
Personal Information
Name: (surname) (first) (middle)

Address: (street, RRff, PO Box) (town/city) (province) (postal code)

Social Insurance Number Date of Birth (yy/mm/dd) Marital □ Single O Married

Status: q Divorced □ Common law (see **)

Spouse’s/Partner's Name: (surname) (first) (middle) Date of Birth (yy/mm/dd)

Home Phone Number: Number of Dependent children and Ages: (Dependent children are those children who are living
with you and for whom you and/or your spouse/partner are legally responsible.)

Residential Information
Landlord's Name: Monthly Rent:
$
Landlord's Address:

Name of Mortgage Company (if you are a homeowner): Monthly Mortgage Payment (if you are
a homeowner): $

Address of Mortgage Company (if you are a homeowner):

Mortgage Balance (if you are a homeowner): Approximate Property Value (if you are a homeowner): Equity (if you are a homeowner):
$ $ $
Tax Information (You and your spouse/partner must submit a copy of your most recent Notice of Assessment from
Canada Revenue Agency to substantiate the Tax Information entered below.)

Enter your Total Income from Line 150 of your Enter your spouse’s/partner's Total Income from Line 150 of your
current Income Tax Return: spouse's/partner's current Income Tax Return:
$ $
Family Income
Your Place of Employment or Self-Employment: Position: Monthly Salary (net):
$
Address of Employment: Business Phone Number:

Spouse’s/Partner’s Place of Employment or Self-Employment: Position: Monthly Salary (net):

$
Spouse’s/Partner’s Address of Employment: Business Phone Number:

Other Source(s) and Amount(s) of Iricome

Child support $ Disability Pension $
Rental income $ Worker’s Compensation $
Old Age Security $ Income Support (Alberta Works) $
AISH $ Band Funding $
Canada Pension Plan $ Child Tax Credit Benefit $
Universal Child Care Benefits $ Other(s) $

See Reverse Side July 2015 Page 500

Family Monthly Expenses (you may Description Monthly Outstanding
be asked to submit proof of extraordinary
expenses) Payment Balance

Student Aid (include Canada $ $

and Alberta student aid)

Rent/Mortgage/T axes $ $

Insurance $ $

Utilities $ $

Telephone $ $

Food $ $

Child Care/Support $ $

Transportation $ $

Uninsured Medical Expenses $ $

Other (e.g. clothing, personal care, etc. $ $

TOTAL $ $

Assets
Vehicles Owned/Leased (indicate if by Applicant or Make: Model and year: Vehicle Equity:
by spouse/partner): $

Other Assets (specify type of asset, value, and date of purchase, e.g. stocks, bonds, RRSPs, GICs, etc. and whether owned by Applicant or
spouse/partner):

Banking Information of Applicant and Spouse/Partner

Name and Full Address of Branch: Type of Account: Balance:
$

Name and Full Address of Branch: Type of Account: Balance:

$

** Definition of common law: You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal relationship continuously for the past one year, or
• you have declared an individual to have a status equivalent to that of your common law partner under any law of Alberta or
of Canada, or
• you and an individual are living together in a conjugal relationship where there are one or more children of the relationship
by birth or adoption

APPLICANT CERTIFICATION
I certify that the inform ation contained in this schedule is accurate and fairly states the current m arket value of m y real
and personal property. I understand that the inform ation on this form and obtained from third parties m ay be used for
the purpose of determ ining and verifying m y eligibility fo r the A lberta Special C onsideration program .

S ignature of A p p lic a n t:____________________________________________________ Date: ___________________________

SPOUSE/PARTNER CERTIFICATION
I certify that the inform ation contained in this schedule is accurate and fairly states the current m arket value of m y real
and personal property. I understand that the inform ation on this form and obtained from third parties m ay be used for
the purpose of determ ining and verifying the A p p lica n t’s eligibility fo r the A lberta S pecial C onsideration program .

S ignature of S p o u s e /P a rtn e r:_____________________________________________ Date: __________________________

UPLOAD OR MAIL YOUR FORM

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using
e-Document Upload
Or mail to: Student Aid Alberta, Program Payments & Revenue Support, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4

See Reverse Side July 2015 Page 501

 Program Payments & Schedule J - Income and
^4dbetbfiji Revenue Support
PO Box 28000 Stn Main
Edmonton AB T5J 4R4
Expense Statement
Student Aid Alberta for Special Consideration
Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the
Freedom of Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant’s eligibility for the Alberta
Special Consideration program and for the administration (including for research, statistical analysis and evaluations) and
enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta), as may be
amended from time to time. The use and disclosure of personal information is managed in accordance with the Freedom of
Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or disclosure of this
information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also
mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Debt Information Alberta Student Number I I I n

Alberta Student Loan Balance Owing: Grant Overpayment Balance Owing:
$ $
Personal Information
Name: (surname) (first) (middle)

Address: (street, RRff, PO Box) (town/city) (province) (postal code)

Social Insurance Number Date of Birth (yy/mm/dd) Marital □ Single O Married

Status: q Divorced □ Common law (see **)

Spouse’s/Partner's Name: (surname) (first) (middle) Date of Birth (yy/mm/dd)

Home Phone Number: Number of Dependent children and Ages: (Dependent children are those children who are living
with you and for whom you and/or your spouse/partner are legally responsible.)

Residential Information
Landlord's Name: Monthly Rent:
$
Landlord's Address:

Name of Mortgage Company (if you are a homeowner): Monthly Mortgage Payment (if you are
a homeowner): $

Address of Mortgage Company (if you are a homeowner):

Mortgage Balance (if you are a homeowner): Approximate Property Value (if you are a homeowner): Equity (if you are a homeowner):
$ $ $
Tax Information (You and your spouse/partner must submit a copy of your most recent Notice of Assessment from
Canada Revenue Agency to substantiate the Tax Information entered below.)

Enter your Total Income from Line 150 of your Enter your spouse’s/partner's Total Income from Line 150 of your
current Income Tax Return: spouse's/partner's current Income Tax Return:
$ $
Family Income
Your Place of Employment or Self-Employment: Position: Monthly Salary (net):
$
Address of Employment: Business Phone Number:

Spouse’s/Partner’s Place of Employment or Self-Employment: Position: Monthly Salary (net):

$
Spouse’s/Partner’s Address of Employment: Business Phone Number:

Other Source(s) and Amount(s) of Iricome

Child support $ Disability Pension $
Rental income $ Worker’s Compensation $
Old Age Security $ Income Support (Alberta Works) $
AISH $ Band Funding $
Canada Pension Plan $ Child Tax Credit Benefit $
Universal Child Care Benefits $ Other(s) $

See Reverse Side November 2014 P3Qe 5 0 2

Family Monthly Expenses (you may Description Monthly Outstanding
be asked to submit proof of extraordinary
expenses) Payment Balance

Student Aid (include Canada $ $

and Alberta student aid)

Rent/Mortgage/T axes $ $

Insurance $ $

Utilities $ $

Telephone $ $

Food $ $

Child Care/Support $ $

Transportation $ $

Uninsured Medical Expenses $ $

Other (e.g. clothing, personal care, etc. $ $

TOTAL $ $

Assets
Vehicles Owned/Leased (indicate if by Applicant or Make: Model and year: Vehicle Equity:
by spouse/partner): $

Other Assets (specify type of asset, value, and date of purchase, e.g. stocks, bonds, RRSPs, GICs, etc. and whether owned by Applicant or
spouse/partner):

Banking Information of Applicant and Spouse/Partner

Name and Full Address of Branch: Type of Account: Balance:
$

Name and Full Address of Branch: Type of Account: Balance:

$

** Definition of common law: You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal relationship continuously for the past one year, or
• you have declared an individual to have a status equivalent to that of your common law partner under any law of Alberta or
of Canada, or
• you and an individual are living together in a conjugal relationship where there are one or more children of the relationship
by birth or adoption

APPLICANT CERTIFICATION
I certify that the inform ation contained in this schedule is accurate and fairly states the current m arket value of m y real
and personal property. I understand that the inform ation on this form and obtained from third parties m ay be used for
the purpose of determ ining and verifying m y eligibility fo r the A lberta Special C onsideration program .

S ignature of A p p lic a n t:____________________________________________________ Date:

SPOUSE/PARTNER CERTIFICATION
I certify that the inform ation contained in this schedule is accurate and fairly states the current m arket value of m y real
and personal property. I understand that the inform ation on this form and obtained from third parties m ay be used for
the purpose of determ ining and verifying the A p p lica n t’s eligibility fo r the A lberta S pecial C onsideration program .

S ignature of S p o u se /P a rtn e r:_____________________________________________ Date:

See Reverse Side November 2014 P3Qe 503

 Schedule K - Medical Questionnaire
Program Payments & for the Alberta Repayment Assistance Plan
”®v®nue ®^pp°rt „ for Borrowers with Permanent Disabilities
Edmonton ab T5j 4R4 (RAP-PD) or Special Consideration
Student Aid Alberta
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant's eligibility for the
Alberta Repayment Assistance Plan for Borrowers with Permanent Disabilities (RAP-PD) or the Alberta Special
Consideration program and for the administration (including for research, statistical analysis and evaluations) and
enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta), as
may be amended from time to time. The use and disclosure of personal information is managed in accordance with the
Freedom o f Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or
disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4.

APPLICANT’S NAME DATE OF BIRTH

Day Month Year

ALBERTA STUDENT NUMBER

APPLICANT’S ADDRESS....................................................................................................................
(street, RR#, PO Box) (town/city) (province) (postal code)

Applicant’s Consent: I hereby authorize my doctor to disclose the following personal health
information to Innovation and Advanced Education who in turn may disclose it to the Canada Student
Loans Program, the National Student Loans Service Centre, and the Student Aid Alberta Service
Centre for the purpose of determining and verifying my eligibility for Alberta RAP-PD or the Alberta
Special Consideration program, as applicable. I understand why I have been asked to disclose my
personal health information, and am aware of the risks and benefits of consenting, or refusing to
consent, to the disclosure of my personal health information. I understand this consent will be valid
indefinitely from the date I signed unless I expressly revoke my authorization in writing, which I may
do at any time. This consent is obtained in accordance with the Health Information Act (Alberta).

Applicant’s Signature

Witness’ Name (please print) Witness’ Signature Date

Any cost incurred to complete this questionnaire is the responsibility of the patient.

Information for the Doctor

• Please complete the medical questionnaire on the reverse side.
• T h e q u e s tio n n a ire w ill a s s is t S tu d e n t A id A lb e rta in d e te rm in in g w h e th e r y o u r p a tie n t (“th e
A p p lic a n t” ) q u a lifie s fo r R A P -P D o r S p e c ia l C o n s id e ra tio n b y re a s o n o f a p e rm a n e n t d is a b ility .
• Y o u m a y s u b s titu te th is m e d ic a l q u e s tio n n a ire w ith a le tte r o r s ig n e d c o m p u te r p rin to u t th a t
p ro v id e s th e s a m e in fo rm a tio n .
• A d e la y in c o m p le tin g th is m e d ic a l q u e s tio n n a ire m a y a ffe c t th e A p p lic a n t’s e n title m e n t to
R A P -P D o r S p e c ia l C o n s id e ra tio n .
• T h e in fo rm a tio n y o u p ro v id e o n th is m e d ic a l q u e s tio n n a ire w ill b e a d m in is te re d in a c c o rd a n c e
w ith th e FreedomofInformationandProtectionofPrivacyAct {A lb e rta ) a n d , u p o n re q u e s t,
m a y b e a c c e s s ib le b y th e A p p lic a n t.
• It is a n o ffe n c e to m a k e a fa ls e o r m is le a d in g s ta te m e n t in a m e d ic a l q u e s tio n n a ire fo r R A P -P D
o r S p e c ia l C o n s id e ra tio n .

Instructions once questionnaire is completed

Y o u m a y re tu rn th e c o m p le te d m e d ic a l q u e s tio n n a ire :
• to th e A p p lic a n t, o r
• m a il to : S tu d e n t A id A lb e rta , P ro g ra m P a y m e n ts & R e v e n u e S u p p o rt, P O B o x 28000 S tn
M a in , E d m o n to n A B T 5 J 4 R 4
If you decide to mail the report directly to Student Aid Alberta, please advise the Applicant.

UPLOAD OR MAIL YOUR FORM (Instructions for Applicant)

Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in via SFS Login 3. Submit securely using
e-Document Upload
Or mail to: Student Aid Alberta, Program Payments & Revenue Support, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4

July 2015
Page 504
TO BE COMPLETED BY DOCTOR
1. H o w lo n g h a v e y o u k n o w n th e A p p lic a n t?

2. N a tu re o f illn e s s (e s ) o r d is a b ility (ie s ):

3. W h e n d id th e illn e s s o r d is a b ility c o m m e n c e ? II II
Day Month Year
4. Is th e illn e s s (e s ) o r d is a b ility (ie s ) te m p o ra ry o r p e rm a n e n t?

5. If te m p o ra ry , w h a t is th e e x p e c te d d a te o f re c o v e ry ?

6. D o e s th e illn e s s (e s ) o r p e rm a n e n t d is a b ility (ie s ) re s u lt in a fu n c tio n a l lim ita tio n th a t re s tric ts th e

a b ility o f th e A p p lic a n t to p e rfo rm th e d a ily a c tiv itie s n e c e s s a ry to p a rtic ip a te fu lly in s tu d ie s a t a
p o s t-s e c o n d a ry le v e l o r th e la b o u r fo rc e ?

7. W h a t e d u c a tio n o r la b o u r fo rc e b a rrie rs d o e s th e A p p lic a n t h a v e a s a re s u lt o f th e ir illn e s s (e s ) o r

p e rm a n e n t d is a b ility (ie s ), a n d h o w d o th e y re s tric t th e A p p lic a n t fro m fu lly p a rtic ip a tin g in p o s t­
s e c o n d a ry s tu d ie s o r in th e la b o u r fo rc e ?

8. Is th e illn e s s (e s ) o r p e rm a n e n t d is a b ility (ie s ) lik e ly to s u b s ta n tia lly re d u c e th is p e rs o n ’s life tim e

e a rn in g c a p a c ity ? Explain:

9. A d d itio n a l c o m m e n ts :

I certify that the information provided on this form is accurate and that the applicant identified in
this assessment experiences the disability-related educational and/or employment barriers
indicated.

D o c to r’s N a m e a n d A d d re s s (Please affix with rubber stamp or seal).

Doctor’s Signature

Telephone Number

Date

July 2015
Page 505
 Schedule K - Medical Questionnaire
Program Payments & for the Alberta Repayment Assistance Plan
”®v®nue ®^pp°rt „ for Borrowers with Permanent Disabilities
Edmonton ab T5j 4R4 (RAP-PD) or Special Consideration
Student Aid Alberta
Innovation and Advanced Education is collecting this personal information under the authority of section 33(c) of the
Freedom o f Information and Protection of Privacy Act (Alberta) to determine and verify the Applicant's eligibility for the
Alberta Repayment Assistance Plan for Borrowers with Permanent Disabilities (RAP-PD) or the Alberta Special
Consideration program and for the administration (including for research, statistical analysis and evaluations) and
enforcement of student financial assistance programs in accordance with the Student Financial Assistance Act (Alberta), as
may be amended from time to time. The use and disclosure of personal information is managed in accordance with the
Freedom o f Information and Protection of Privacy Act (Alberta). If you have any questions about the collection, use or
disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North
America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box 28000 Stn Main, Edmonton AB
T5J 4R4.

APPLICANT’S NAME DATE OF BIRTH

Day Month Year

ALBERTA STUDENT NUMBER

APPLICANT’S ADDRESS....................................................................................................................
(street, PR#, PO Box) (town/city) (province) (postal code)

Applicant’s Consent: I h e re b y a u th o riz e m y d o c to r to d is c lo s e th e fo llo w in g p e rs o n a l h e a lth

in fo rm a tio n to In n o v a tio n a n d A d v a n c e d E d u c a tio n w h o in tu rn m a y d is c lo s e it to th e C a n a d a S tu d e n t
L o a n s P ro g ra m , th e N a tio n a l S tu d e n t L o a n s S e rv ic e C e n tre , a n d th e S tu d e n t A id A lb e rta S e rv ic e
C e n tre fo r th e p u rp o s e o f d e te rm in in g a n d v e rify in g m y e lig ib ility fo r A lb e rta R A P -P D o r th e A lb e rta
S p e c ia l C o n s id e ra tio n p ro g ra m , a s a p p lic a b le . I u n d e rs ta n d w h y I h a v e b e e n a s k e d to d is c lo s e m y
p e rs o n a l h e a lth in fo rm a tio n , a n d a m a w a re o f th e ris k s a n d b e n e fits o f c o n s e n tin g , o r re fu s in g to
c o n s e n t, to th e d is c lo s u re o f m y p e rs o n a l h e a lth in fo rm a tio n . I u n d e rs ta n d th is c o n s e n t w ill b e v a lid
in d e fin ite ly fro m th e d a te I s ig n e d u n le s s I e x p re s s ly re v o k e m y a u th o riz a tio n in w ritin g , w h ic h I m a y
d o a t a n y tim e . T h is c o n s e n t is o b ta in e d in a c c o rd a n c e w ith th e HealthInformationAct (A lb e rta ).

Applicant’s Signature

Witness’ Name (please print) Witness’ Signature Date

Any cost incurred to complete this questionnaire is the responsibility of the patient.

INFORMATION FOR THE DOCTOR

• Please complete the medical questionnaire on the reverse side.
• T h e q u e s tio n n a ir e w ill a s s is t S tu d e n t A id A lb e r ta in d e te r m in in g w h e th e r y o u r p a tie n t (“th e
A p p lic a n t” ) q u a lifie s fo r R A P - P D o r S p e c ia l C o n s id e r a tio n b y r e a s o n o f a p e r m a n e n t
d is a b ility .
• Y o u m a y s u b s titu te th is m e d ic a l q u e s tio n n a ir e w ith a le tte r o r s ig n e d c o m p u te r p r in to u t
th a t p r o v id e s th e s a m e in fo r m a tio n .
• A d e la y in c o m p le tin g th is m e d ic a l q u e s tio n n a ir e m a y a ffe c t th e A p p lic a n t ’s e n title m e n t to
R A P - P D o r S p e c ia l C o n s id e r a tio n .
• T h e in fo r m a tio n y o u p r o v id e o n th is m e d ic a l q u e s tio n n a ir e w ill b e a d m in is te r e d in
a c c o r d a n c e w ith th e FreedomofInformationandProtectionofPrivacyAct ( A lb e r ta ) a n d ,
u p o n r e q u e s t, m a y b e a c c e s s ib le b y th e A p p lic a n t.
• It is a n o ffe n c e to m a k e a fa ls e o r m is le a d in g s ta te m e n t in a m e d ic a l q u e s tio n n a ir e fo r
R A P - P D o r S p e c ia l C o n s id e r a tio n .

INSTRUCTIONS ONCE QUESTIONNAIRE IS COMPLETED

Y o u m a y re tu rn th e c o m p le te d m e d ic a l q u e s tio n n a ire to th e A p p lic a n t o r d ire c tly to :
S tu d e n t A id A lb e rta
P ro g ra m P a y m e n ts & R e v e n u e S u p p o rt
P O B o x 2 8 0 0 0 S tn M a in
E d m o n to n A B T 5 J 4 R 4

If you decide to mail the report directly to Student Aid Alberta,

please advise the Applicant.

June 2014
Page 506
TO BE COMPLETED BY DOCTOR
1. H o w lo n g h a v e y o u k n o w n th e A p p lic a n t?

2. N a tu re o f illn e s s (e s ) o r d is a b ility (ie s ):

3. W h e n d id th e illn e s s o r d is a b ility c o m m e n c e ? II II
Day Month Year
4. Is th e illn e s s (e s ) o r d is a b ility (ie s ) te m p o ra ry o r p e rm a n e n t?

5. If te m p o ra ry , w h a t is th e e x p e c te d d a te o f re c o v e ry ?

6. D o e s th e illn e s s (e s ) o r p e rm a n e n t d is a b ility (ie s ) re s u lt in a fu n c tio n a l lim ita tio n th a t re s tric ts th e

a b ility o f th e A p p lic a n t to p e rfo rm th e d a ily a c tiv itie s n e c e s s a ry to p a rtic ip a te fu lly in s tu d ie s a t a
p o s t-s e c o n d a ry le v e l o r th e la b o u r fo rc e ?

7. W h a t e d u c a tio n o r la b o u r fo rc e b a rrie rs d o e s th e A p p lic a n t h a v e a s a re s u lt o f th e ir illn e s s (e s ) o r

p e rm a n e n t d is a b ility (ie s ), a n d h o w d o th e y re s tric t th e A p p lic a n t fro m fu lly p a rtic ip a tin g in p o s t­
s e c o n d a ry s tu d ie s o r in th e la b o u r fo rc e ?

8. Is th e illn e s s (e s ) o r p e rm a n e n t d is a b ility (ie s ) lik e ly to s u b s ta n tia lly re d u c e th is p e r s o n ’s life tim e

e a rn in g c a p a c ity ? Explain:

9. A d d itio n a l c o m m e n ts :

I certify that the information provided on this form is accurate and that the applicant identified in
this assessment experiences the disability-related educational and/or employment barriers
indicated.

D o c to r’s N a m e a n d A d d re s s (Please affix with rubber stamp or seal).

Doctor’s Signature

Telephone Number

Date

June 2014
Page 507
 Student Aid Alberta

Alberta Barley Commission

Eugene Boyko Memorial
Scholarship

m
Page 508
 The Alberta Barley Commission - Eugene Boyko Memorial Scholarship
T h e E u g e n e B o y k o M e m o ria l S c h o la r s h ip w a s c r e a te d in 2 0 0 2 b y th e A lb e r ta B a rle y C o m m is s io n to re c o g n iz e a n d e n c o u ra g e
s tu d e n ts e n te r in g th e fie ld o f c ro p p r o d u c tio n a n d /o r c ro p p r o c e s s in g te c h n o lo g y s tu d ie s .

E u g n e B o y k o , w h o p a s s e d a w a y in th e s p r in g o f 2 0 0 1 , w a s a lo n g tim e d ir e c to r o f th e A lb e r ta B a r le y C o m m is s io n . H e w a s k n o w n
f o r h is c o m m itm e n t to a g r ic u ltu r e a n d s u p p o r t o f im p ro v e d a n d in n o v a tiv e fa r m in g te c h n iq u e s .

Award Value - $500

Eligibility Criteria
A p p lic a n t m u s t b e:
a. a C a n a d ia n c itiz e n o r p e r m a n e n t r e s id e n t a n d b e a n A lb e r ta re s id e n t,
b. a tte n d in g a d e s ig n a te d p o s t - s e c o n d a r y in s titu tio n in A lb e rta ,
c. e n r o lle d in th e s e c o n d o r s u b s e q u e n t y e a r o f p o s t- s e c o n d a r y s tu d y ,
d. e n r o lle d fu ll-tim e in c o u rs e s w ith a n e m p h a s is o n c r o p p ro d u c tio n a n d /o r c ro p p r o c e s s in g te c h n o lo g y , a n d
d. m u s t n o t h a v e p re v io u s ly r e c e iv e d th is s c h o la rs h ip .

Selection Procedure
T h e r e c ip ie n t w ill b e s e le c te d o n th e b a s is o f a c a d e m ic a c h ie v e m e n t in th e p re v io u s y e a r o f p o s t- s e c o n d a r y stu d y .

Application Procedure *

S u b m it to A lb e r ta S c h o la r s h ip P ro g ra m s :
* a c o m p le te d a p p lic a tio n fo r m , a n d
* a n o ff ic ia l tra n s c rip t.

S tu d e n ts w ill b e n o tif ie d o f th e s ta tu s o f th e ir a p p lic a tio n in N o v e m b e r a n d th e a w a r d is is s u e d a f te r A lb e r ta S c h o la r s h ip P ro g r a m s

c o n firm s f u ll-tim e e n r o lm e n t in c o u rs e s r e la te d to c ro p p r o d u c tio n a n d /o r c r o p p r o c e s s in g te c h n o lo g y .

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P r o g r a m s A lb e r ta S c h o la r s h ip P r o g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2 V 1

T e le p h o n e : 7 8 0 .4 2 7 .8 6 4 0
E m a il: s c h o la r s h ip s @ g o v .a b .c a
V isit: s tu d e n ta id .a lb e r ta .c a /s c h o la r s h ip s

The Alberta Heritage Scholarship Fund

F u n d e d b y a $ 1 0 0 m illio n e n d o w m e n t fro m th e A lb e r ta H e r ita g e S a v in g s T ru s t F u n d , th e A lb e r ta H e r ita g e S c h o la r s h ip F u n d is
d e s ig n e d to s tim u la te th e p u rs u it o f e x c e lle n c e b y r e c o g n iz in g o u ts ta n d in g a c h ie v e m e n t a n d b y e n c o u r a g in g a n d a s s is tin g A lb e r ta n s
to a c h ie v e th e i r fu lle s t p o te n tia l.

Application Deadline: August 1

Page 509
 The Alberta Barley Commission-Eugene Boyko Memorial Scholarship

W e a rc c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f the F ree d o m o f In fo rm a tio n a n d P ro tectio n
o f P r iv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r e lig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a s e c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F loor, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 -4 2 7 -8 6 4 0 .

Personal Information

A lb e rta S tu d e n t N u m b e r (go to www.education.gov.ab.ca to find your ASN or to obtain one) S ocial In su ra n c e N u m b e r (required for processing)

- a s t N a m e (current full legal name) Please use upper and lower case. F irs t N a m e a n d u n e in itia l (current ful legal name)

M a ilin g A d d r e s s (Include Apt. or Box Number) E ity /T o w n

P ro v in c e C o u n try P o s ta l C o d e A re a C o d e e le p h o n e N u m b e r

G e n d e r (circle one) D a te o f B irth E m a i l A d d re s s

M F day month year
__ I__ ' I

CITIZENSHIP ( c h e c k one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)

Note: Attach a a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e rta ? H a v e y o u liv e d in A lb e r ta a ll y o u r life ? I f ‘N O ’ s in c e
Y N Y N month year
___ I___ ___ I____I____I___

If you have answered “NO” to both residency questions above, please include a letter explaining the time you spent
in Alberta as a non full-time student.

POST-SECONDARY STUDIES (S tu d y in A lb e rta in c o u rse s re la te d to c ro p p ro d u c tio n a n d /o r c ro p p ro c e ss in g tech n o lo g y .)

P o s t-S e c o n d a ry . ID . N u m b e r N a m e o f P ro g r a m

N a m e o t In s titu tio n A c a d e m ic S ta rt D a te A c a d e m ic E n d D a te
month year month year
I I I I I ___ I 1___ 1__ 1 ' 1
In s titu tio n C ity L e n g th o f P ro g r a m Y e a r o f P ro g r a m

Page 510
 Please list the crop-related courses you are enrolled in for the academic year 2015-2016
and explain how your program of study is related to crop production and/or crop
processing technology:

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E THA T:
a. a ll in f o rm a tio n p ro v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tify th e o ff ic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r itin g i f I w ith d r a w fro m fu ll-tim e s tu d ie s b e fo r e
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D E R ST A N D A N D A G R E E THAT:
a. m y p e r s o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic re c o r d m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n
A lb e r ta S c h o la r s h ip P r o g r a m s , S tu d e n t A id A lb e r ta fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility f o r a s c h o la rs h ip ,
b. m y p e rs o n a l in f o r m a tio n p e r ta in in g to m y p o s t - s e c o n d a r y e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n
A lb e r ta S c h o la r s h ip P r o g r a m s , S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l in s titu tio n f o r th e p u r p o s e o f d e te r m in in g m y
e lig ib ility f o r a s c h o la rs h ip ,
c. m y p e rs o n a l in f o rm a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P ro g r a m s , S tu d e n t A id A lb e rta
a n d a n y p r o v in c ia l g o v e r n m e n t d e p a r tm e n ts , b o a rd s o r in s titu tio n s to v e rify th e in f o rm a tio n I h a v e p r o v id e d to A lb e rta
S c h o la r s h ip P ro g r a m s , S tu d e n t A id A lb e r ta a n d fo r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D ER ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e re le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is n o t a
c r ite r io n f o r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g r a m s , S tu d e n t A id A lb e rta .

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on: studentaid.alberta.ca/scholarships

Page 511
 Student Aid Alberta

Alberta Excellence in
Agriculture Scholarship

Page 512
 Alberta Excellence in Agriculture Scholarship

T h e A lb e r ta E x c e lle n c e in A g r ic u ltu r e S c h o la r s h ip w a s e s ta b lis h e d b y th e A lb e r ta W h e a t B o a rd M o n ie s T ru s t to e n c o u r a g e a c a d e m ic

e x c e lle n c e o f s tu d e n ts e n r o lle d in a p o s t - s e c o n d a r y p r o g r a m in a d is c ip lin e re la te d to th e f ie ld o f a g ric u ltu re .

Award Value - Two awards of $3,000

Eligibility Criteria
A p p lic a n t m u s t b e :
a. a C a n a d ia n c itiz e n o r p e r m a n e n t r e s id e n t a n d b e a n A lb e r ta r e s id e n t,
b. e n r o lle d fu ll-tim e in th e s e c o n d o r s u b s e q u e n t y e a r o f p o s t- s e c o n d a r y s tu d y in a d ip lo m a o r d e g r e e p r o g r a m a t o n e o f th e
fo llo w in g A lb e r ta p o s t - s e c o n d a r y in s titu tio n in a d is c ip lin e re la te d to a g ric u ltu re :

Olds College: A g r ic u ltu r e M a n a g e m e n t, A n im a l H e a lth T e c h n o lo g y , E q u in e S c ie n c e , P r o d u c tio n H o r tic u ltu r e , a n d B a c h e lo r

o f A p p lie d S c ie n c e - P r o d u c tio n , H o rtic u ltu re , A g r ib u s in e s s
Lethbridge College: A n im a l S c ie n c e , P la n t a n d S o il S c ie n c e
Lakeland College: A g r ib u s in e s s , A n im a l H e a lth T e c h n o lo g y , A n im a l S c ie n c e T e c h n o lo g y , C ro p T e c h n o lo g y
NAIT: A n im a l H e a lth T e c h n o lo g y
University o f Calgary: F a c u lty o f V e te rin a ry M e d ic in e
University o f Alberta: D e p a rtm e n t o f A g r ic u ltu r a l, F o o d a n d N u tr itio n a l S c ie n c e
University o f Lethbridge: A g ric u ltu re , B io te c h n o lo g y o r A g ric u ltu ra l S tu d ie s in th e F a c u lty o f A rts a n d S c ie n c e

Selection Procedure
T h e r e c ip ie n t w ill b e s e le c te d o n th e b a s is o f a c a d e m ic a c h ie v e m e n t in th e p r e v io u s y e a r o f p o s t- s e c o n d a r y stu d y .

Application Procedure*
S u b m it to A lb e r ta S c h o la r s h ip P ro g ra m s :
* a c o m p le te d a p p lic a tio n fo rm , a n d
* a n o ff ic ia l tra n s c rip t.

S tu d e n ts w ill b e n o tif ie d o f th e s ta tu s o f th e i r a p p lic a tio n in N o v e m b e r a n d th e a w a rd w ill b e is s u e d a f te r A lb e r ta S c h o la r s h ip P ro g r a m s

c o n firm s f u ll-tim e e n ro lm e n t.

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 7 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2V 1
Phone: 7 8 0 4 2 7 - 8 6 4 0
Email: s c h o la rs h ip s @ g o v .a b .c a
Visit: s t u d e n ta id .a lb e r ta .c a /s c h o la r s h ip s

The Alberta Heritage Scholarship Fund

F u n d e d b y a $ 1 0 0 m illio n e n d o w m e n t fr o m th e A lb e r ta H e rita g e S a v in g s T ru s t F u n d , th e A lb e r ta H e rita g e S c h o la r s h ip F u n d is d e s ig n e d
to s tim u la te th e p u r s u it o f e x c e lle n c e b y re c o g n iz in g o u ts ta n d in g a c h ie v e m e n t a n d b y e n c o u r a g in g a n d a s s is tin g A lb e r ta n s to a c h ie v e
th e i r f u lle s t p o te n tia l.

Application Deadline: August 1

Page 513
 Alberta Excellence in Agriculture Scholarship
W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F ree d o m o f In fo rm a tio n a n d P ro te ctio n
o f P rivacy’ A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r e lig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a s e c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F loor, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 4 2 7 -8 6 4 0 .

Personal Information
A lb e rta S tu d e n t N u m b e r (go to www.cducation.gov.ab.ca to find your ASN or to obtain one) S ocial In su ra n c e N u m b e r (required for processing)

Last Name (current full legal name) Please use upper and lower case. first Name and Une ini la l (current full legal name)

M a ilin g A d d r e s s (Include Apt. or Box Number) C ity /T o w n

P ro v in c e C o u n try P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

G e n d e r (c ir c le o n e ) D a te o f B irth E m a il A d d re s s
M day I m o n th ye a r
j ____ L _ i ____ J ____ I____ L

CITIZENSHIP ( c h e c k one)

CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)

1-------1 '------ ' Note: A t ta c h a a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e r ta ? H a v e y o u liv e d in A lb e r ta a ll y o u r life ? I f ‘N O ’ s in c e
Y N Y N m o n th year

_____ I_____ _____ I_____ I_____ I_____

I f y ou h a v e a n sw e re d “ N O ” to b o th re sid e n c y q u e stio n s ab o v e, p lease in c lu d e a le tte r e x p la in in g th e tim e you s p e n t in A lb e rta as

a n o n -fu ll-tim c stu d e n t.

POST-SECONDARY STUDIES (S tu d y in A lb e rta in a p ro g ra m o f s tu d y re la te d to th e field o f a g ric u ltu re .

P o s t-S e c o n d a ry . ID . N u m b e r N a m e o f P ro g ram

'la m e o f I n s titu tio n A c a d e m ic S ta rt D a te A c a d e m ic E n d D a te

m b n th year
_____ I______L _ i ______ i______I______

In s titu tio n C ity L e n g th o f P r o g r a m Y e a r o f P ro g r a m

Page 514
 For your application to be considered, you must include a copy of your
academic transcript. An unofficial transcript is acceptable.

Information on other awards is available on studentaid.alberta.ca/scholarships

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E THA T:
a. a ll in f o rm a tio n p ro v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tify th e o ff ic e o f A lb e r ta S c h o la r s h ip P ro g r a m s , S tu d e n t A id in w r itin g i f I w ith d r a w fro m f u ll­
tim e s tu d ie s b e f o r e c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D E R ST A N D A N D A G R E E THAT:
a. m y p e r s o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic re c o r d m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s , S tu d e n t A id f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ,
b. m y p e rs o n a l in f o r m a tio n p e r ta in in g to m y p o s t - s e c o n d a r y e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s , S tu d e n t A id a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y
e lig ib ility f o r a s c h o la rs h ip ,
c. m y p e rs o n a l in f o rm a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P ro g r a m s , S tu d e n t A id
a n d a n y p r o v in c ia l g o v e r n m e n t d e p a r tm e n ts , b o a rd s o r in s titu tio n s to v e rify th e in f o rm a tio n I h a v e p r o v id e d to A lb e rta
S c h o la r s h ip P ro g r a m s , S tu d e n t A id a n d fo r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D ER ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e re le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is
n o t a c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P r o g r a m s , S tu d e n t A id .

Signature of Applicant (in ink) Today’s Date (in ink)

Page 515
 Student Aid Alberta

Alberta Federation of
Agriculture Scholarship

Page 516
 Alberta Federation of Agriculture Scholarship

T h e A lb e r ta F e d e ra tio n o f A g r ic u ltu r e e s ta b lis h e d a s c h o la rs h ip e n d o w m e n t to r e c o g n iz e th e a c a d e m ic a c h ie v e m e n t o f s tu d e n ts p u rs in g

p o s t - s e c o n d a r y s tu d ie s in th e fie ld o f a g r ic u ltu r e a n d re la te d p ro g r a m s .

Award Value - $500

Eligibility Criteria
A p p lic a n t m u s t b e :
a. a C a n a d ia n c itiz e n o r p e r m a n e n t r e s id e n t a n d b e a n A lb e r ta re s id e n t,
b. a tte n d in g a d e s ig n a te d p o s t- s e c o n d a r y in s titu tio n in A lb e rta , a n d
c. e n r o lle d fu ll-tim e in th e s e c o n d o r s u b s e q u e n t y e a r o f p o s t - s e c o n d a r y s tu d y in a p r o g r a m re la te d to th e f ie ld o f a g ric u ltu re .

P re f e re n c e w ill b e g iv e n to m e m b e rs , c h ild re n o r g r a n d c h ild r e n o f m e m b e r s o f th e A lb r ta F e d e ra tio n o f A g ric u ltu re .

Selection Procedure
T h e r e c ip ie n t w ill b e s e le c te d o n th e b a s is o f a c a d e m ic a c h ie v e m e n t in th e p r e v io u s y e a r o f p o s t - s e c o n d a r y stu d y .

Application Procedure*

S u b m it to A lb e r ta S c h o la r s h ip P ro g r a m s :
* a c o m p le te d a p p lic a tio n fo rm , a n d
* a n o ff ic ia l tr a n s c rip t.

S tu d e n ts w ill b e n o tifie d o f th e s ta tu s o f th e i r a p p lic a tio n in N o v e m b e r a n d th e a w a r d w ill b e is s u e d a f t e r A lb e r ta S c h o la r s h ip P ro g r a m s

c o n f ir m s fu ll-tim e e n ro lm e n t.

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2 V 1

T e le p h o n e : 7 8 0 4 2 7 - 8 6 4 0
E m a il: s c h o la rs h ip s @ g o v .a b .c a
W e b s ite : s t u d e n tta id .a lb e r ta .c a /s c h o la r s h ip s

The Alberta Heritage Scholarship Fund

F u n d e d b y a $ 1 0 0 m illio n e n d o w m e n t fr o m th e A lb e r ta H e rita g e S a v in g s T r u s t F u n d , th e A lb e r ta H e r ita g e S c h o la r s h ip F u n d is d e s ig n e d to
s tim u la te th e p u r s u it o f e x c e lle n c e b y r e c o g n iz in g o u ts ta n d in g a c h ie v e m e n t a n d b y e n c o u r a g in g a n d a s s is tin g A lb e r ta n s to a c h ie v e th e ir
fu lle s t p o te n tia l.

Application Deadline: August 1

Page 517
 Alberta Federation of Agriculture Scholarship

W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F ree d o m o f In fo rm a tio n a n d P ro te ctio n

o f P r iv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a se c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F loor, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 -4 2 7 -8 6 4 0 .

Personal Information
A lb e rta S tudent N u m b e r (go to w w w .education.gov.ab.ca to find your ASN or to obtain one) S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current full legal nam e) Please use upper and lower case. F ir s t N a m e a n d O n e In itia l (current full legal name)

M a ilin g A d d r e s s (Include Apt, or Box Number) C ity /T o w n

P ro v in c e C o u n try P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

G ender (circle one) D a te o f B irth E m a il A d d re s s

M f la y | m p n th | ■ yepr |

CITIZENSHIP ( c h e c k one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)

N o t e : A t ta c h a a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
Y N Y N m o n th year
_____ I_____ _____ I_____ I_____ I_____
I f y ou h a v e a n sw e re d “ N O ” to b o th re sid en c y q u e stio n s a b o v e , p lea se in c lu d e a le tte r e x p la in in g th e tim e y o u s p e n t in A lb e rta as
a n o n -fu ll-tim e stu d e n t.

Are you a member or the son/daughter or grandson/granddaughter of a member of the Alberta Federation of
Agriculture? If yes, please provide the full name of the member;_______________________________________

POST-SECONDARY STUDIES (S tu d y in A lb e rta in a p r o g r a m o f s tu d y re la te d to th e field o f a g ric u ltu re .

P o s t-S e c o n d a ry . ID . N u m b e r N a m e o f P ro g r a m

N a m e o f In s titu tio n A c a d e m ic S ta rt D a te A c a d e m ic E n d D a te
m b n th ye a r mbnth
no year
_____ i_____ L _ j _____ i_____ i_____

In s titu tio n C ity L e n g th o f P r o g r a m Y e a r o f P ro g r a m

3 rd 4 th

Office Use On y
118 8 8 8 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

Jisbursement E

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: March 2015

Page 518
 If you are pursuing a program of study which is indirectly related to the field of
agriculture, please explain how you view your program of study relative to the field
of agriculture:

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E TH A T:
a. a ll in f o rm a tio n p ro v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tif y th e o ff ic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r itin g i f I w ith d r a w fro m fu ll-tim e s tu d ie s
b e fo r e c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D E R ST A N D A N D A G R E E THAT:
a. m y p e rs o n a l in f o r m a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic re c o r d m a y b e r e le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ,
b. m y p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r
a s c h o la rs h ip ,
c. m y p e rs o n a l in f o rm a tio n m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y
p r o v in c ia l g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o rm a tio n I h a v e p r o v id e d to A lb e r ta
S c h o la r s h ip P r o g r a m s , a n d fo r th e u s e in re s e a rc h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D E R ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is
n o t a c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e rta S c h o la r s h ip P ro g ra m s .

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards is available on: studentaid.alberta.ca/scholarships

Page 519
 Student Aid Alberta

Alberta Ukrainian Centennial

Commemorative Scholarship

Page 520
 Alberta Ukrainian Centennial Commemorative Scholarship
T h e A lb e r ta U k ra in ia n C e n te n n ia l C o m m e m o r a tiv e S c h o la r s h ip p r o g r a m w a s e s ta b lis h e d in 1991 b y th e n P re m ie r o f A lb e rta ,
D o n G e tty , o n th e o c c a s io n o f th e 100 th a n n iv e rs a ry o f th e first U k ra in ia n s e ttle m e n t in C a n a d a . T h e s c h o la rs h ip a c k n o w le d g e s
th e s ig n ific a n t c o n trib u tio n s o f U k ra in ia n s e ttle rs in A lb e rta a n d to c o m m e m o ra te th e C e n te n n ia l o f U k ra in ia n s e ttle m e n ts in
C a n a d a a n d A lb e rta (1 8 9 1 -1 9 9 1 ).

Award Value
Up to $25,000

T h e a w a rd c o v e rs e d u c a tio n a l c o s ts (b o o k s a n d tu itio n ), liv in g c o s ts , c o v e ra g e o f A lb e r ta H e a lth a n d B lu e C ro s s , a n d o n e

r e tu r n a irfa re .

Eligibility Criteria
O n e s c h o la r s h ip fo r a s tu d e n t fr o m U k ra in e to s tu d y in A lb e r ta a n d o n e s c h o la r s h ip fo r a s t u d e n t fr o m A lb e r ta to s tu d y in
U k ra in e . A p p lic a n ts m u s t b e e n r o lle d o r p la n n in g to e n ro ll f u ll-tim e a t th e D o c to ra l o r M a s te r le v e l.
W h ile th e fie ld o f s tu d y is o p e n , p r e f e r e n c e m a y b e g iv e n to s tu d e n ts in U k ra in ia n la n g u a g e s tu d ie s , C a n a d ia n U k ra in ia n
s tu d ie s , o r a r e a s o f d e m o n s tr a b le b e n e f it to e it h e r A lb e r ta , U k ra in e o r b o th .
A p p lic a n ts m u s t d e m o n s tr a te p r o f ic ie n c y in th e u s e o f th e E n g lis h /U k r a in ia n la n g u a g e a c c e p ta b le to th e in s titu tio n a tte n d e d .
S c h o la r s h ip s c a n b e e x te n d e d fo r a s e c o n d y e a r o f s tu d y u p o n p r o o f o f s a tis f a c to r y a c a d e m ic p ro g r e s s .

Application Procedures
T h e a p p lic a tio n fo rm is a v a ila b le o n th e S tu d e n t A id A lb e rta w e b s ite . A p p lic a n ts m u s t m a il in a p p lic a tio n fo rm s w ith a n y
a p p lic a b le a tta c h m e n ts , u n s ta p le d . T ra n s c rip ts a n d re fe re n c e s m u s t a c c o m p a n y y o u r a p p lic a tio n . S tu d e n ts m u s t m a il th e ir
a p p lic a tio n s to:

Mail to:
S tu d e n t A id A lb e rta
P O B o x 2 8 0 0 0 S ta tio n M a in
E d m o n to n , A lb e rta T 5 J 4 R 4

Incomplete applications will not be submitted to the committee. Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

For information on this scholarship and other awards:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Selection Criteria
A p p lic a tio n s a re e v a lu a te d b y a c o m m itte e a p p o in te d b y th e P re s id e n ts o f th e u n iv e r s itie s in A lb e rta . A p p lic a tio n s a re
j u d g e d o n p r e v io u s a c a d e m ic a c c o m p lis h m e n ts , p r o g r a m o f s tu d y , re f e r e n c e s , a n s w e r s to th e e s s a y q u e s tio n , a n d g e n e ra l
im p r e s s io n s fro m th e a p p lic a tio n fo rm .

Application Deadline:

February 15 postmark for Study in the following September.

Transcripts and references must accompany your application.

Page 521
 Alberta Ukrainian Centennial Commemorative Scholarship

A d v a n c e d E d u c a tio n is c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is form u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F ree d o m o f In fo rm a tio n
a n d P ro te c tio n o f P r iv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a n a w a rd u n d e r the
A lb e rta H e rita g e S c h o la rsh ip A c t a n d to a d m in is te r A lb e rta S ch o larsh ip s. I f y o u h a v e a n y q u e stio n s ab o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a se c o n ta c t S tu d en t A id A lb erta, P O B ox 2 8 0 0 0 S tatio n M ain , E d m o n to n , A B T 5 J 4R 4.

Personal Information

S o c ia l I n s u ra n c e N u m b e r (required for processing)

L a s t N a m e (curent full legal nam e) Please use upper and low er case. F ir s t N a m e a n d O n e In itia l (current full legal name)

M a ilin g A d d r e s s (Include Apt. or Box Number) C ity /T o w n

P ro v in c e P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

D a te o f B irth G ender E m a il A d d re s s
M F
____ ____ i____ ____i____ i____ i____
day m o n th year

CITIZENSHIP ( c h e c k o n e )
] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
N o t e : In c lu d e a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd o r im m ig r a tio n lo n g fo r m . V is a s tu d e n ts a re n o t e lig ib le .

CITIZEN OF UKRAINE

C o n tin u o u s R e s id e n t in A lb e rta fro m : C o n tin u o u s R e s id e n t in U k ra in e fro m :

m onth/year: _________________________ m onth/year: __________________________

POST-SECONDARY EDUCATION
H ig h e s t d e g re e c o m p le te d :

C u r r e n t in s titu tio n : N a m e o f p ro g r a m :

OR L a s t in s titu tio n a tte n d e d : N a m e o f p ro g ra m :

Revised: Jan. 2016

Page 522
 Education Information
(Note: This award is for graduate study: Doctoral or Master level)

N a m e o f in s titu tio n y o u w iU a tte n d th is fa ll?

L e v el o f s tu d y ( c h e c k o n e):
^ M a s te rs | | P h .D .

W h a t is y o u r T h e s is o r P r o je c t title ? _________

P le a s e s u b m it a re s u m e a n d in c lu d e th e fo llo w in g : a ll u n iv e r s itie s , c o lle g e s o r te c h n ic a l in s titu te s a tte n d e d to d a te , in c lu d in g

c u rr e n t in s titu tio n ; lis t s c h o la r s h ip s , a w a rd s a n d o th e r fo r m s o f a c h ie v e m e n t re c e iv e d ; in d ic a te a n y p u b lic a tio n s , i f a n y , s u c h a s
th e n a m e o f th e jo u r n a l th e y w e re p u b lis h e d in , a ls o in c lu d e , i f a p p lic a b le , a n y p r e s e n ta tio n s /p e r f o r m a n c e s /e x h ib itio n s (d a te s ,
lo c a tio n s , e tc .).

Essay Question

Title of your proposed program of study: __________________________________________

In two pages or less, please provide a detailed description of your proposed program of study, why you are
pursuing your research (if applicable) and what you plan to accomplish during and after your studies.

Please attach these pages (unstapled) to your application. Pages must be single-spaced, and enough space
between the lines for legibility, approximately six lines per vertical inch. Font size should not be less than 10 and
condensed type is not acceptable.

Application Deadline:

February 15 postmark for Study in the following September.

Transcripts and references must also be postmarked no later than February 15.

Page 523
 C om plete a p p lic a tio n package m u st be postm a rke d no later than February 15.

O ffic ia l tra n s c rip ts and references m u st also be postm arked no later than February 15.

References

N a m e th e tw o in d iv id u a ls p r o v id in g le tte r s o f r e f e re n c e .

A s m a n y a p p lic a n ts c o m p e te fo r a lim ite d n u m b e r o f a w a r d s , e n s u r e re f e re n c e s p r o v id e d e ta ile d in f o rm a tio n o n th e

a p p li c a n t’s b a c k g r o u n d , p r o g r a m o f s tu d y , a c c o m p lis h m e n ts a n d a re a o f r e s e a rc h .

N am e P o s itio n H e ld

In s titu tio n

N am e P o s itio n H e ld

In s titu tio n

B e lo w , list th e in s titu tio n s p r o v id in g y o u r tr a n s c r ip ts ( in c lu d e y o u r s u r n a m e i f it is d if f e r e n t o n th e tr a n s c rip t) . I f y o u

a p p lie d la s t y e a r a n d w is h to u s e th e s a m e tr a n s c r ip t, p le a s e in d ic a te th e s p e c ific tr a n s c rip t( s ).

Page 524
 Declaration of Applicant
I h a v e re a d a n d u n d e r s ta n d th e in s tru c tio n , a n d d e c la r e th a t

a. a ll in f o rm a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to v e rific a to n ;

b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d fo r th e p e r io d s ta te d ;

c. I w ill im m e d ia te ly n o tif y S tu d e n t A id A lb e r ta w r itin g i f I w ith d r a w fr o m f u ll-tim e S tu d ie s

b e fo r e c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I u n d e r s ta n d a n d a g re e th a t

a. m y p e rs o n a l in f o r m a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic re c o r d m a y b e re le a s e d
a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l in s titu tio n f o r th e
p u rp o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ;

b. m y p e r s o n a l in f o r m a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y
b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l
in s titu tio n fo r th e p u rp o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ;

c. m y p e rso n a l in fo rm a tio n m a y b e re le a se d a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e rta and

a n y p ro v in c ia l g o v e rn m e n t d e p a rtm e n ts, b o a rd s o r in stitu tio n s to v e rify th e in fo rm a tio n I h a v e
p ro v id e d to S tu d e n t A id A lb e rta a n d fo r th e u se in re s e a rc h a n d sta tistical a n a ly sis in p ro g ra m
e v alu a tio n .

I u n d e r s ta n d a n d a g re e th a t

i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to

p ro m o te th e p r o g r a m , h o w e v e r, th is is n o t a c r ite r io n f o r e lig ib ility , a n d i f I d o n o t w a n t to
b e id e n tif ie d , I w ill c o n ta c t S tu d e n t A id A lb e rta .

Signature of Applicant (in ink) Today’s Date (in ink)

C om plete a p p lic a tio n package m u st be postm arked no later than February 15.
O ffic ia l tra n s c rip ts and references m u st accom pany y o u r a p p lica tio n .
N o tific a tio n o f re su lts m ay be expected in May.

Alberta Heritage Scholarship Fund

F u n d e d b y a $ 1 0 0 m illio n e n d o w m e n t fr o m th e A lb e r ta H e rita g e S a v in g s T ru s t F u n d , th e A lb e r ta H e r ita g e S c h o la r s h ip F u n d
is d e s ig n e d to s tim u la te th e p u r s u it o f e x c e lle n c e b y r e c o g n iz in g o u ts ta n d in g a c h ie v e m e n t a n d b y e n c o u r a g in g a n d a s s is tin g
A lb e rta n s to a c h ie v e th e i r f u lle s t p o te n tia l.

S tu d e n t A id A lb e rta a d m in is te rs a n o th e r g ra d u a te s c h o la rsh ip , th e A rts G ra d u a te A w a rd fo r M a s te r lev el s tu d y in th e fie ld o f th e A rts.

In fo rm a tio n o n th is s c h o la rsh ip is a v a ila b le o n o u r w e b site .

Information on other awards is available on: studentaid.alberta.ca/scholarships

Page 525
 Student Aid Alberta

Anna and John Kolesar

Memorial Scholarship

Page 526
 Anna and John Kolesar Memorial Scholarship
T h is s c h o la rs h ip h o n o u r s th e m e m o ry o f A n n a a n d J o h n K o le s a r, th e p a r e n ts o f D r. H e n ry K o le s a r, D e p u ty M in is te r o f A lb e rta
A d v a n c e d E d u c a tio n fro m 1 9 7 6 to 1 9 8 7 . L o n g tim e r e s id e n ts o f th e M ille t a re a , th e K o le s a r s w e re life lo n g a d v o c a te s o f th e
im p o rta n c e o f h ig h e r e d u c a tio n , p r o v id in g e n c o u r a g e m e n t a n d s u p p o r t to a ll w h o c h o s e a c a d e m ic p u rs u its . O rig in a lly fro m
H u n g a ry , A n n a a n d J o h n K o le s a r a rr iv e d in A lb e r ta in 1 9 2 7 , c o n tr ib u tin g m u c h to th e i r c o m m u n ity a n d p r o v in c e in th e m a n y y e a rs
th e y liv e d in M ille t. U p o n h is r e tir e m e n t in 1 9 8 7 , D r. K o le s a r in itia te d th e s c h o la r s h ip w ith a g e n e r o u s e n d o w m e n t th a t w a s
s u p p o r te d b y c o n tr ib u tio n s fr o m fr ie n d s a n d c o lle a g u e s .

Award Value - $1,500

Eligibility Criteria
A p p lic a n t m u s t:
a. b e a C a n a d ia n c itiz e n o r a P e r m a n e n t R e s id e n t,
b. b e a n A lb e r ta r e s id e n t - th e a p p lic a n t o r th e a p p li c a n t’s p a r e n t( s ) m u s t h a v e r e s id e d in A lb e r ta d u r in g th e
q u a lif y in g g ra d e s ,
c. b e fr o m a f a m ily w h e r e n e ith e r p a r e n t o b ta in e d a u n iv e r s ity d e g r e e , a n d
c. in te n d to p u r s u e a p r o g r a m o f s tu d y in a F a c u lty o f E d u c a tio n .

Selection Procedure
T h e r e c ip ie n t w ill b e s e le c te d o n th e b a s is o f a c a d e m ic e x c e lle n c e a s c a lc u la te d fro m th e fin a l s ta n d in g s r e c e iv e d in th r e e s u b je c ts a s
re c o r d e d o n a n A lb e r ta E d u c a tio n tr a n s c rip t. T h e s u b je c ts s h a ll in c lu d e :

One of: E n g lis h 3 0 , E n g lis h 3 0 - 1, 3 0 -2 o r F r a n c a is 3 0 , 3 0 -2 a n d

Any two of the following: P u re M a th e m a tic s 3 0 A p p lie d M a th e m a tic s 3 0 M a th e m a tic s 3 1

M a th e m a tic s 31 S c ie n c e 3 0 M a th e m a tic s 3 0 -1 , o r 3 0 -2
B io lo g y 3 0 C h e m is tr y 3 0 P h y s ic s 3 0
S o c ia l S tu d ie s 3 0 , 3 0 -1 o r 3 0 -2 o r a la n g u a g e o th e r th a n th e o n e u s e d a b o v e a t th e G ra d e 12 le v e l

In th e e v e n t o f a tie th e a p p lic a n t w ith th e h ig h e s t a v e r a g e o f th e D ip lo m a E x a m in a tio n m a r k s fo r th e q u a lif y in g c o u rs e s w ill b e th e

re c ip ie n t.

Application Procedure

A p p lic a n ts w ill b e n o tifie d o f th e s ta tu s o f th e i r a p p lic a tio n in S e p te m b e r. T h e a w a r d w ill b e is s u e d in N o v e m b e r a f te r A lb e rta

S c h o la r s h ip P r o g r a m s c o n f ir m s th e r e c i p ie n t’s fu ll-tim e e n r o lm e n t in a F a c u lty o f E d u c a tio n .

FAXED OR SCANNED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 4 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2V 1

P h o n e: 7 8 0 4 2 7 -8 6 4 0
E m a il: s c h o la r s h ip s @ g o v .a b .c a
V isit: s t u d e n ta id .a lb e r ta .c a /s c h o la r s h ip s

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is designed to
stimulate the pursuit o f excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to achieve their fullest
potential.

Application Deadline: July 1

Page 527
 Anna and John Kolesar Memorial Scholarship
W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c) o f th e F re e d o m o f In fo rm a tio n a n d P ro te ctio n
o f P r iv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a s e c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F lo o r, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T5K. 2V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information
A lb e rta S tu d en t N u m b e r H ig h S ch o o l C o d e S ocial In su ra n c e N u m b e r (required fo r processing)

L ast N am e (c u rre n t fu ll leg a l nam e) Please use u pp e r and lo w e r case. F irs t N a m e a n d O n e In itia l (c u rre n t fu ll legal nam e)

M a ilin g A d d r e s s (In c lu d e A p t. o r B o x N u m b e r) C ity /T o w n

P re v io u s S u rn a m e
P ro v in c e C o u n tr y P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

G ender (c ir c le o n e ) B irth d a te E m a il

M day month year

___ L __ ___ I___ ___ L _ l ___ I___
H a v e e ith e r o f y o u r p a r e n ts o b ta in e d a u n iv e r s ity d e g re e ? Y N

CITIZENSHIP ( c h e c k o n e )
CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)
'--------- • I------- 1 NN
n toatre :A A
t ttatar h
c ha an h
p nh tonto
r rcmo p
v yn o
f n
f pp rem
rma napnnetn trtre
'sirt e netn tr acraHrdn ro ri mim
s id mmi oig
r artai tnio
n nI nlo
nan gf fo r m . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e r ta ? D id y o u r p a r e n ts liv e in A lb e r ta w h ile y o u w e re in h ig h s c h o o l?

Y N Y N

H a v e y o u liv e d in A lb e rta a ll y o u r life ?

IF YOU ANSWERED ‘NO’ TO EITHER OF THESE QUESTIONS
Y N S in c e month year PLEASE INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
___ I_______ I__ _J___ I___

PROPOSED POST-SECONDARY STUDIES

N a m e o f In s titu tio n I n s titu tio n C o d e (N o te : See b e lo w fo r in s titu tio n codes.)

In s titu tio n C ity E n try D a te fo r P ro g r a m P ro g r a m

m tjn th | j yptt

P O S T - S E C O N D A R Y S T U D E N T I.D . N U M B E R

Office Use Only

67 8 8 8 1 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: April 2015

Page 528
 Personal Information (continued)

SECONDARY EDUCATION
N a m e o f H ig h S c h o o l

T o w n /C ity P ro v in c e

D a te o f C o m p le tio n o f H ig h S c h o o l H a v e y o u p r e v io u s ly a p p lie c f o r a n A le x a n d e r R u th e rf o rd S c h o la r s h ip ?
Y N I f ‘Y E S ’ w h a t y e a r?
i i i i
month year

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E TH A T:
a. a ll in f o rm a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d fo r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tif y th e o ffic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r it in g i f I w ith d r a w fr o m f u ll- tim e s tu d ie s b e fo re
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D ER ST A N D A N D A G R E E THAT:
a. p e rs o n a l in f o rm a tio n p e r ta in in g to m y h ig h s c h o o l a c a d e m ic re c o r d m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta
E d u c a tio n a n d A lb e r ta S c h o la r s h ip P r o g r a m s f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ,
b. p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility f o r a
s c h o la rs h ip ,
c. m y p e rs o n a l in f o r m a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y p ro v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o rm a tio n I h a v e p r o v id e d to A lb e r ta S c h o la r s h ip P ro g r a m s , a n d
f o r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D ER ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e re le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is n o t a
c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g ra m s .

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
I f y o u r in s titu tio n c o d e is n o t lis te d h e re , s e e th e lis t o f P u b lic ly F u n d e d In s titu tio n s .

U n iv e r s ity o f A l b e r t a ........................... ...2201 C o n c o r d ia U n iv e r s ity C o lle g e ( A B ) ..2 2 4 6 M o u n t R o y a l U n iv e r s ity 2243

U n iv e r s ity o f C a l g a r y .......................... ...2 2 0 2
U n iv e r s ity o f L e t h b r i d g e ................... ...2 2 0 3
N A I T ............................................................. ...2 2 2 1
S A I T ............................................................. ...2 2 2 2
A lb e rta C o lle g e o f A rt & D e s ig n ... ...5 1 1 0
A m b ro s e U n i v e r s i t y ............................ ...9041
A th a b a s c a U n iv e r s ity ........................... ...2 2 0 4
B o w V a lle y C o l l e g e .............................. ...2 2 1 8
D c v ry I n s titu te o f T e c h n o lo g y ........ ....2 0 4 0
G r a n d e P ra irie R e g io n a l C o lle g e ... ....2 2 4 1
G ra n t M a c E w a n U n i v e r s i t y .............. ....2 2 4 7
K e y a n o C o l l e g e ...................................... ....2 2 3 0
K in g s U n iv e rs ity C o l l e g e .................. ....2 2 5 5
L a k e la n d C o l l e g e ................................... ....2 2 2 5
L e th b r id g e C o l l e g e ............................... ....2 2 2 0
M e d ic in e H a t C o l l e g e .......................... ....2 2 4 2
N o r th e r n L a k e s C o ll e g e e ........... ............2 0 2 0
N o r q u e s t C o l l e g e .......................... ............ 2 2 2 6
O ld s C o l l e g e ................................... ............ 2 2 2 4
P o rta g e C o ll e g e .............................. ............ 2 2 1 9
R e d D e e r C o ll e g e .......................... ............ 2 2 4 4
S t. M a r y ’s .......................................... ............ 5661
T a y lo r U n i v e r s i t y .......................... ............ 2 2 6 8

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 Student Aid Alberta

Arts Graduate Scholarship

■

Page 530
 Arts Graduate Scholarship
T h e A r ts G ra d u a te S c h o la r s h ip e n c o u r a g e s a n d re c o g n iz e s A lb e r ta s tu d e n ts w h o h a v e d e m o n s tr a te d o u ts ta n d in g a b ilitie s in th e a rts to
p u r s u e g ra d u a te s tu d ie s . T h is s c h o la r s h ip is fu n d e d b y A lb e rta H e rita g e S c h o la r s h ip F u n d .

Award Value - $15,000

Eligibility Criteria

U p to s e v e n a w a rd s a re a v a ila b le fo r m a s te r le v e l o r e q u iv a le n t le v e l o f s tu d y in m u s ic , d ra m a , d a n c e a n d lite ra ry /v is u a l arts.

A p p lic a n ts m u s t b e :

• a C a n a d ia n c itiz e n o r a P e r m a n e n t R e s id e n t,
• a n A lb e r ta r e s id e n t, a n d
• e n r o lle d o r p la n n in g to e n ro ll fu ll-tim e in a g ra d u a te p r o g r a m a t th e m a s te r le v e l o r e q u iv a le n t.

P re v io u s r e c ip ie n ts a re e lig ib le to re -a p p ly . A n in d iv id u a l m a y re c e iv e a m a x im u m o f tw o a w a rd s .
R e c ip ie n ts m a y h o ld o th e r a w a rd s a n d a c c e p t r e m u n e r a tiv e a s s ig n m e n ts d e p e n d in g o n th e p o lic y o f th e in s titu tio n th e y a tte n d .

Application Procedure
T h e a p p lic a tio n fo rm is a v a ila b le o n th e S tu d e n t A id A lb e rta w e b s ite . A p p lic a n ts m u s t m a il in a p p lic a tio n fo rm s w ith a n y a p p lic a b le
a tta c h m e n ts , u n s ta p le d . A c a d e m ic tra n s c rip ts a n d re fe re n c e s m u s t a c c o m p a n y y o u r a p p lic a tio n . S tu d e n ts m u s t m a il th e ir a p p lic a tio n s to:

Mail to:
S tu d e n t A id A lb e rta
P O B o x 2 8 0 0 0 S ta tio n M a in
E d m o n to n , A lb e rta T 5 J 4 R 4

Incomplete applications will not be submitted to the committee. Faxed applications are not accepted.
Student Aid Alberta no longer accepts scholarship applications dropped off in person.

For information on this scholarship and other awards:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Selection Criteria
A p p lic a tio n s a re e v a lu a te d b y a c o m m itte e a p p o in te d b y th e P re s id e n ts o f th e u n iv e r s itie s in A lb e rta . A p p lic a tio n s a re j u d g e d o n
p r e v io u s a c a d e m ic a c c o m p lis h m e n ts , p r o g r a m o f s tu d y , re f e re n c e s , a n s w e rs to th e e s s a y q u e s tio n a n d g e n e r a l im p re s s io n s fr o m th e
a p p lic a tio n f o n n .

Application Deadline:

February 15 postmark for Study in the following September.

Transcripts and references must accompany your application. ^
 Arts Graduate Scholarship

A d v a n c e d E d u c a tio n is c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is form u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e F ree d o m o f

In fo rm a tio n a n d P ro te ctio n o f P r iv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r an a w a rd
u n d e r th e A lb e rta H e rita g e S c h o la rsh ip A c t a n d to a d m in is te r A lb e rta S ch o larsh ip s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f this
in fo rm a tio n , p le a se c o n ta c t S tu d en t A id A lb e rta , P O B o x 2 8 0 0 0 S tatio n M a in , E d m o n to n , A B T 5 J 4R 4.

Personal Information

You may use the Learner Registry at www.cducation.gov.ab.ca to find your Alberta Student Number or to have one assigned

A lb e r ta S tu d e n t N u m b e r (re q u ire d fo r p ro ce ssin g) S o c ia l I n s u ra n c e N u m b e r (re q u ire d fo r proce ssin g)

L ast N am e (c u re n l fu ll legal n am e ) Please use u pp e r and lo w e r case. F irs t N a m e a n d O n e In itia l (c u rre n t fu ll leg a l nam e)

M a ilin g A d d r e s s (In c lu d e A p t, o r B o x N u m b e r) C ity /T o w n

P ro v in c e P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

D a te o f B irth G ender E m a il
M F
___ l___ ___ i___ ___ i____i____i___
day m o n th year

CITIZENSHIP ( c h e c k one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)

N o t e : A t ta c h a p h o to c o p y o f p e r m a n e n t re s id e n t c a rd . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
H a v e y o u liv e d in A lb e rta a ll v o u r life ? Is A lb e rta th e la s t p la c e v o u s p e n t 12 c o n s e c u tiv e m o n th s
Y N I f n o , s in c e o u ts id e o f s c h o o l? Y N
___ I___ ___ I____I____I___
m o n th year

D o e ith e r o f y o u r p a r e n ts liv e in A lb e r ta ?

POST-SECONDARY EDUCATION
H ig h e s t d e g re e c o m p le te d :

C u r r e n t in s titu tio n : N a m e o f p ro g r a m :

OR L a s t in s titu tio n a tte n d e d : N a m e o f p ro g ra m :

Office Use Only

94 8 8 8 1 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t

MO YR AUTHORIZATION AW ARD KEY APP KEY

Revised: Jan. 2016

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 Education Information

N a m e o f in s titu tio n y o u w ill a tte n d th is fa ll:

L e v el o f s tu d y ( c h e c k o n e):

M a s te r L e v e l ] O th e r

N a m e o f T h c s is /P r o je c t T itle :

P le a s e s u b m it a re s u m e a n d in c lu d e th e fo llo w in g : A ll u n iv e r s itie s , c o lle g e s o r te c h n ic a l in s titu te s a tte n d e d to d a te , in c lu d in g

c u rr e n t in s titu tio n ; lis t s c h o la r s h ip s , a w a rd s , a n d o th e r fo r m s o f a c h ie v e m e n t r e c e iv e d ; in d ic a te a n y p u b lic a tio n s , i f a n y , s u c h a s
th e n a m e o f th e jo u r n a l th e y w e re p u b lis h e d in , a n d a ls o in c lu d e p e r f o r m a n c e s /e x h ib ilio n s ( d a te s , lo c a tio n , e tc .).

Essay Question

Title of your proposed program of study:

In tw o p a g e s o r le s s, p le a s e p r o v id e a d e ta ile d d e s c r ip tio n o f y o u r p r o p o s e d p r o g r a m o f s tu d y , w h y y o u a re
p u r s u in g y o u r re s e a rc h ( i f a p p lic a b le ) o r c r e a tiv e a c tiv ity , a n d w h a t y o u p la n to a c c o m p lis h d u r in g a n d a fte r
y o u r s tu d ie s .

P le a s e a tta c h th e s e tw o p a g e s to y o u r a p p lic a tio n . P a g e s m u s t b e s in g le - s p a c e d , a n d e n o u g h s p a c e b e tw e e n th e lin e s fo r

le g ib ility , a p p r o x im a te ly six lin e s p e r v e rtic a l in c h . F o n t s iz e s h o u ld n o t b e le s s th a n 10 a n d c o n d e n s e d ty p e is n o t
a c c e p ta b le .

Academic Transcripts
L is t th e in s titu tio n s p r o v id in g tr a n s c r ip ts (in c lu d e y o u r s u r n a m e i f it is d if f e r e n t o n th e tr a n s c rip t) . I f y o u a p p lie d la s t y e a r a n d
w is h to u s e th e s a m e tr a n s c r ip ts , p le a s e in d ic a te th e s p e c ific tr a n s c r ip t( s ) b e lo w :

Page 533
 References

N a m e th e tw o in d iv id u a ls p r o v id in g le tte r s o f re f e re n c e . A s n u m e r o u s a p p lic a n ts c o m p e te to w a r d s a lim ite d n u m b e r

o f a w a rd s , e n s u r e r e f e r e n c e s p r o v id e d e ta ile d in f o rm a tio n o n th e a p p li c a n t’s p r o g r a m o f s tu d y , re s e a rc h
( i f a p p lic a b le ) , a n d a c c o m p lis h m e n ts .

1) N am e: _______________________________________________________________________________

P o s itio n H e ld : --------------------------------------------------------------------------------------------------------------

In s titu tio n : ___________________________________________________________________________

2) N am e: ________________________________________________________________________________

P o s itio n H e l d : _________________________________________________________________________

In s titu tio n : ___________________________________________________________________________

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N , A N D D E C L A R E T H A T

a. a ll in f o rm a tio n p ro v id e d is tru e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to v e rific a tio n ;

b. I w ill b e a f u ll- tim e s tu d e n t a t th e in s titu tio n n a m e d f o r th e p e r io d s ta te d ;

c. I w ill im m e d ia te ly n o tif y S tu d e n t A id A lb e r ta in w r itin g i f I w ith d r a w fr o m fu ll-tim e s tu d ie s

b e fo r e c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D ER STA N D A N D A G R EE THAT

a. m y p e r s o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic re c o r d m a y b e r e le a s e d a n d
e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l in s titu tio n f o r th e p u r p o s e o f
d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ;

b. m y p e r s o n a l in f o rm a tio n p e r ta in in g to m y p o s t - s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y b e
re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l in s titu tio n fo r
th e p u r p o s e o f d e te r m in in g m y e lig ib ility f o r a s c h o la rs h ip ;

c. m y p e rso n a l in fo rm a tio n m a y b e re le a se d a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e rta a n d a n y

p ro v in c ia l g o v e rn m e n t d e p a rtm e n ts, b o a rd s o r in stitu tio n s to v e rify th e in fo rm a tio n I h a v e p ro v id e d to
S tu d e n t A id A lb e rta a n d fo r th e u se in re se a rc h a n d statistical a n a ly sis in p ro g ra m e v a lu a tio n .

I U N D E R S T A N D A N D A G R E E THAT:

i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a rd a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p ro m o te th e p ro g r a m .

H o w e v e r, th is is n o t a c r ite r io n fo r e lig ib ility , a n d i f I d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t
S tu d e n t A id A lb e rta .

Signature of Applicant (in ink) Today’s Date (in ink)

Page 534
 Alberta Heritage Scholarship Fund
Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage
Scholarship Fund is designed to stimulate the pursuit of excellence by recognizing outstanding
achievement and by encouraging and assisting Albertans to achieve their fullest potential.

Student Aid Alberta administers another graduate scholarship, the Sir James Lougheed Award of Distinction
for study outside Alberta. Information on this award is available on studentaid.alberta.ca

Your completed application package must be postmarked no later than February 15.
Official transcripts and references must accompany your application.
Notification of results may be expected in April.

Page 535
 Student Aid Alberta

Maria Sava Polish Heritage

Awards and Scholarships

Page 536
 Maria Sava Polish Heritage Awards and Scholarships
T h e s e a w a r d s a n d s c h o la r s h ip s r e c o g n iz e th e e x c e lle n c e o f s tu d e n ts fro m th e J a n P a w e l II P o lis h B ilin g u a l P r o g r a m o f E m o n to n
C a th o lic S c h o o ls a n d a s s is t th e m in c o n tin u in g th e i r e d u c a tio n a t th e p o s t- s e c o n d a r y le v e l. T h e p r o g r a m w a s n a m e d in m e m o ry o f
M a r ia S a v a , w h o w a s in s tru m e n ta l in e s ta b lis h in g th e b ilin g u a l p r o g r a m a n d ta u g h t a t th e s c h o o l f o r o v e r 2 0 y e a rs .

Award Value
Three scholarships and two awards of $1,000 each

Eligibility Criteria
A p p lic a n t m u s t:
a. b e a C a n a d ia n c itiz e n o r a P e rm a n e n t R e s id e n t,
b. b e a n A lb e r ta r e s id e n t,
c. h a v e ta k e n a ll o f G ra d e s 7 , 8 a n d 9 a t J a n P a w e l II s c h o o l, a n d
d. e n ro ll fu ll-tim e in a n y p r o g r a m o f s tu d y a t th e p o s t- s e c o n d a r y le v e l.

S tu d e n ts n o r m a lly a p p ly in th e y e a r th e y g r a d u a te fr o m h ig h s c h o o l. I f a s tu d e n t m is s e s th e d e a d lin e th e y m a y a p p ly in a s u b s e q u e n t
y e a r. R e c ip ie n ts c a n o n ly re c e iv e th is a w a r d o n c e .

Selection Criteria
T h e three scholarship recipients w ill b e s e le c te d o n th e b a s is o f a c a d e m ic e x c e lle n c e a s c a lc u la te d fr o m th e fin a l s ta n d in g s in fiv e
c o u r s e s in G r a d e 12 u s in g th e A le x a n d e r R u th e r f o r d S c h o la r s h ip c o u rs e c r ite r ia a s fo llo w s :

One of: E n g lis h 3 0 , E n g lis h 3 0 - 1 , 3 0 - 2 o r F r a n c a is 3 0 , 3 0 -2 a n d

At least two of: P u re M a th e m a tic s 3 0 A p p lie d M a th e m a tic s 3 0 M a th e m a tic s 3 1

M a th e m a tic s 31 S c ie n c e 3 0 M a th e m a tic s 3 0 -1 , o r 3 0 -2
B io lo g y 3 0 C h e m is tr y 3 0 P h y s ic s 3 0
S o c ia l S tu d ie s 3 0 , 3 0 -1 o r 3 0 -2 o r a la n g u a g e o th e r th a n th e o n e u s e d a b o v e a t th e G ra d e 12 le v e l

Any other two courses w ith a m in im u m fiv e c re d it v a lu e a t th e G ra d e 12 le v e l (3 0 0 0 o r 6 0 0 0 s e r ie s ) in c lu d in g th o s e lis te d a b o v e

a n d c o m b in e d a d v a n c e d C T S c o u rs e s .

T h e two award recipients w ill b e s e le c te d b y th e a d m in is tr a tio n a t J a n P a w e l II S c h o o l, a n d s e le c tio n w ill b e b a s e d o n in te rn a l

c rite ria .

Application Procedure

A p p lic a n ts w ill b e n o tifie d o f th e s ta tu s o f th e ir a p p lic a tio n in S e p te m b e r. T h e a w a r d w ill b e is s u e d in N o v e m b e r a f t e r A lb e r ta

S c h o la r s h ip P r o g r a m s c o n f ir m s th e r e c i p ie n t’s fu ll-tim e e n r o lm e n t a t a p o s t - s e c o n d a r y in s titu tio n .

Faxed or scanned applications are not accepted.

Mail to: Courier to:

A lb e r ta S c h o la r s h ip P ro g r a m s A lb e r ta S c h o la r s h ip P ro g r a m s
B o x 2 8 0 0 0 S ta tio n M a in 7 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2V 1

P hone: 7 8 0 4 2 7 -8 6 4 0
E m a il: s c h o la r s h ip s @ g o v .a b .c a
V isit: s t u d e n ta id .a lb e r ta .c a /s c h o la r s h ip s

Application Deadline: July 1

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 Maria Sava Polish Heritage Awards and Scholarships
W e a re c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c) o f th e F ree d o m o f In fo rm a tio n a n d P ro te ctio n
o f P riv a c y A c t (F O IP A c t), a s b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility fo r a sc h o la rsh ip u n d e r th e A lb e rta H e rita g e
S c h o la rsh ip A c t a n d to a d m in is te r th e A lb e rta S c h o la rsh ip P ro g ra m s. I f y o u h a v e a n y q u e stio n s a b o u t th e c o lle c tio n o f th is in fo rm a tio n ,
p le a se c o n ta c t A lb e rta S c h o la rsh ip P ro g ra m s, 4 th F loor, 9 9 4 0 106 S treet, E d m o n to n , A lb e rta , T 5 K 2V 1 P h o n e 7 8 0 .4 2 7 .8 6 4 0 .

Personal Information
A lb e rta S tu d en t N u m b e r H ig h S ch o o l C o d e S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current full legal name) Please use upper and lower case. F irs t N a m e a n d O n e In itia l (current full legal name)

M a ilin g A d d re s s (Include Apt. or Box Num ber) C ity /T o w n

P re v io u s S u rn a m e
P ro v in c e C o u n try P o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

G ender (c ir c le o n e ) B irth d a te E m a il

M day m o n th year
_____ l_ ____ ______I_____ _____ L _ ___I______I_____

DID YOU COMPLETE ALL OF GRADE 7, 8 AND 9 AT JAN PAWEL II SCHOOL? [ ^ ] [ ^ ]

CITIZENSHIP ( c h e c k o n e )
'---------- '
CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)
'--------- ' N o t e : A t ta c h a p h o to c o p y o f p e r m a n e n t r e s id e n t c a rd o r im m ig r a t io n lo n g fo r m . V is a s tu d e n ts a re n o t e lig ib le .

ALBERTA RESIDENCY
D o y o u r p a r e n ts c u r r e n tly liv e in A lb e rta ? D id y o u r p a r e n ts liv e in A lb e rta w h ile y o u w e re in h ig h s c h o o l?

Y N Y N

H a v e y o u liv e d in A lb e rta a ll y o u r life ?

IF YOU ANSWERED ‘NO’ TO EITHER OF THESE QUESTIONS
Y N S in c e m o n th year
PLEASE INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
___ I_______ I__ _l___ I___

PROPOSED POST-SECONDARY STUDIES

N a m e o f In s titu tio n In s titu tio n C o d e (Note: See back page for institution codes.)

In s titu tio n C ity E n try D a te fo r P r o g r a m P ro g ram

nujnth | j yfar {

P O S T - S E C O N D A R Y S T U D E N T I.D . N U M B E R

Office Use Only

Revised: April 2015

Page 538
 Personal Information (continued)

SECONDARY EDUCATION
N a m e o f H ig h S c h o o l

T o w n /C ity P ro v in c e

D a te o f C o m p le tio n o f H ig h S c h o o l H a v e y o u a p p lie d f o r a n A le x a n d e r R u th e rf o rd S c h o la r s h ip ?
Y N I f ‘Y E S ’ w h a t y e a r?
____1________1____ 1____1___
m o n th year

Declaration of Applicant
I H A V E R E A D A N D U N D E R S T A N D T H E IN S T R U C T IO N S , A N D D E C L A R E TH A T:
a. a ll in f o rm a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a fu ll-tim e s tu d e n t a t th e in s titu tio n n a m e d fo r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tif y th e o ffic e o f A lb e r ta S c h o la r s h ip P r o g r a m s in w r it in g i f I w ith d r a w fr o m f u ll- tim e s tu d ie s b e fo re
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I U N D ER ST A N D A N D A G R E E THAT:
a. p e rs o n a l in f o rm a tio n p e r ta in in g to m y h ig h s c h o o l a c a d e m ic re c o r d m a y b e re le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta
E d u c a tio n a n d A lb e r ta S c h o la r s h ip P r o g r a m s f o r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a s c h o la rs h ip ,
b. p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic e n r o lm e n t s ta tu s m a y b e re le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility f o r a
s c h o la rs h ip ,
c. m y p e rs o n a l in f o r m a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n A lb e r ta S c h o la r s h ip P r o g r a m s a n d a n y p ro v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o rm a tio n I h a v e p r o v id e d to A lb e r ta S c h o la r s h ip P ro g r a m s , a n d
f o r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is in p r o g r a m e v a lu a tio n .

I U N D ER ST A N D A N D A G R E E THAT:
i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e re le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is is n o t a
c r ite r io n fo r e lig ib ility , a n d i f f d o n o t w a n t to b e id e n tif ie d , I w ill c o n ta c t A lb e r ta S c h o la r s h ip P ro g ra m s .

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
I f y o u r in s titu tio n c o d e is n o t lis te d h e re , s e e P u b lic ly F u n d e d In s titu tio n s .

U n iv e r s ity o f A l b e r t a ........................... ...2201 C o n c o r d ia U n iv e r s ity C o lle g e ( A B ) ..2 2 4 6 M o u n t R o y a l U n iv e r s ity 2243

U n iv e r s ity o f C a l g a r y .......................... ...2 2 0 2
U n iv e r s ity o f L e t h b r i d g e ................... ...2 2 0 3
N A I T ............................................................. ...2 2 2 1
S A I T ............................................................. ...2 2 2 2
A lb e rta C o lle g e o f A rt & D e s ig n ... ...5 1 1 0
A m b ro s e U n i v e r s i t y ............................ ...9041
A th a b a s c a U n iv e r s ity ........................... ...2 2 0 4
B o w V a lle y C o l l e g e .............................. ...2 2 1 8
D e v ry I n s titu te o f T e c h n o lo g y ........ ....2 0 4 0
G r a n d e P ra irie R e g io n a l C o lle g e ... ....2 2 4 1
G ra n t M a c E w a n U n i v e r s i t y .............. ....2 2 4 7
K e y a n o C o l l e g e ...................................... ....2 2 3 0
K in g s U n iv e rs ity C o l l e g e .................. ....2 2 5 5
L a k e la n d C o l l e g e ................................... ....2 2 2 5
L e th b r id g e C o l l e g e ............................... ....2 2 2 0
M e d ic in e H a t C o l l e g e .......................... ....2 2 4 2
N o r th e r n L a k e s C o ll e g e e ........... ............2 0 2 0
N o r q u e s t C o l l e g e .......................... ............ 2 2 2 6
O ld s C o l l e g e ................................... ............ 2 2 2 4
P o rta g e C o ll e g e .............................. ............ 2 2 1 9
R e d D e e r C o ll e g e .......................... ............ 2 2 4 4
S t. M a r y ’s .......................................... ............ 5661
T a y lo r U n i v e r s i t y .......................... ............ 2 2 6 8

Page 539
 M he^ n Student Aid Alberta

Canadian Oil Sands Network

for Research and Development
CONRAD Scholarship

Page 540
Canadian Oil Sands Network for Research and Development
(CONRAD) Scholarship
T h e C a n a d ia n O il S a n d s N e tw o r k f o r R e s e a r c h a n d D e v e lo p m e n t S c h o la r s h ip re c o g n iz e s th e a c c o m p lis h m e n ts o f s tu d e n ts in
th e i r fin a l y e a r o f s tu d y a t th e u n d e r g r a d u a te a n d g ra d u a te le v e l a n d w h o a re in v o lv e d in p ro je c ts th a t s h o w c o m m e r c ia l p o te n tia l
a n d /o r re le v a n c e .

Eligibility Criteria
A p p lic a n ts m u s t b e :
a. a C a n a d ia n C itiz e n o r a P e rm a n e n t R e s id e n t o f C a n a d a ,
b. a tte n d in g a p o s t- s e c o n d a r y in s titu tio n in A lb e r ta ,
c. e n r o lle d f u ll-tim e in th e i r fin a l y e a r o f s tu d y in a d ip lo m a , u n d e r g r a d u a te d e g re e , o r g ra d u a te le v e l p ro g r a m ,
d. e n ro lle d in a p r o g r a m o f s tu d y re le v a n t to o il s a n d s te c h n o lo g y d e v e lo p m e n t fr o m m in e o r r e s e r v o ir to ta ilin g s a n d
r e m e d ia tio n s u c h a s b u t n o t lim ite d to N a tu r a l o r B io lo g ic a l S c ie n c e s a n d E n g in e e r in g , a n d
e. a c h ie v e a m in im u m G P A o f 3 .0 o n a 4 .0 g ra d e p o in t s c a le .

Value of Award - 2 awards of $5,000

Application Procedure
C o m p le te th e a p p lic a tio n fo r m a n d in c lu d e th e fo llo w in g :

• a n o ff ic ia l a c a d e m ic tr a n s c rip t,
• a o n e p a g e s u m m a ry o f th e p r o je c t a n d its c o m m e rc ia l p o te n tia l, a n d
• a le t te r o f s u p p o r t fr o m a t le a s t o n e s u p e r v is in g p r o f e s s o r o r in s tru c to r, a n d i f a p p lic a b le a s u p p o r tin g le tte r b y a
s p o n s o r in g c o m p a n y .

S u b m it th e a p p lic a tio n fo r m a n d s u p p o r tin g d o c u m e n ts to A lb e r ta S c h o la r s h ip P ro g ra m s .

Selection Procedure
A s e le c tio n c o m m itte e c o m p r is e d o f r e p r e s e n ta tiv e s fr o m fo r m e r C O N R A D M e m b e r c o m p a n ie s w ill r e v ie w tr a n s c rip ts a n d
a p p lic a tio n s a n d d e te r m in e w h ic h s tu d e n ts h a v e d e v e lo p e d a n d a re w o r k in g o n te c h n o lo g ie s , in n o v a tio n s o r p r o c e s s e s s e s w ith
th e h ig h e s t p ro b a b ility o f b e in g c o m m e r c ia lly d e p lo y e d w ith in a r e a s o n a b le tim e f ra m e . T h e c o m m itte e w ill a ls o d e te r m in e a n d
ra n k th e lik e lih o o d o f c o m m e r c ia l v ia b ility o f th e p r o je c ts u n d e r e v a lu a tio n .

Mail to: Courier to:

S tu d e n t A id A lb e rta S tu d e n t A id A lb e rta
B o x 2 8 0 0 0 S ta tio n M a in 7 th F lo o r, 9 9 4 0 106 S tre e t
E d m o n to n , A lb e r ta T 5 J 4 R 4 E d m o n to n , A lb e r ta T 5 K 2 V 1

S tu d e n t A id A lb e rta
C o n ta c t: S tu d e n t A id A lb e rta S e rv ic e C e n tr e a t 1 -8 5 5 -6 0 6 -2 0 9 6
V isit: s tu d e n ta id .a lb e r ta .c a /s c h o la r s h ip s

A p p licatio n Deadline: O cto b er 31

Page 541
 CONRAD Scholarship
In n o v a tio n a n d A d v a n c e d E d u c a tio n is c o lle c tin g th e p e rso n a l in fo rm a tio n o n th is fo rm u n d e r th e a u th o rity o f S e c tio n 3 3 (c ) o f th e
F re e d o m o f In fo rm a tio n a n d P ro te ctio n o f P r iv a c y A c t (F O IP A c t), as b e in g d ire c tly re la te d to a n d n e c e ssa ry to d e te rm in e y o u r elig ib ility
fo r an a w a rd u n d e r th e A lb e rta H e r ita g e S c h o la rsh ip A c t a n d to a d m in is te r A lb e rta S ch o larsh ip s. I f y o u h a v e a n y q u e stio n s a b o u t the
c o lle c tio n o f th is in fo rm a tio n , p le a se c o n ta c t S tu d e n t A id A lb e rta , P O B ox 2 8 0 0 0 S tatio n M a in , E d m o n to n , A B T 5 J 4R 4.

Personal Information
R e tu rn to S tu d e n t A id A lb e rta b y O c to b e r 31

A lb e rta S tu d e n t N u m b e r (required for processing) S o cial In su ra n c e N u m b e r (required for processing)

L a s t N a m e (current legal nam e) Please use upper and lower case. First Name and One Initial (current legal name)

M a ilin g A d d r e s s (Include Apt. or Box Num ber) C ity /T o w n

P re v io u s S u rn a m e _______________
P ro v in c e 5o s ta l C o d e A re a C o d e T e le p h o n e N u m b e r

B irth D a te G e n d e r circle one’ A lte r n a te T e le p h o n e N u m b e r

M F
____l____ ____I____ ____ I____ I____ l____
day month year

CITIZENSHIP ( c h e c k one) E m a il A d d re s s :

C A N A D I A N C IT IZ E N o r

P E R M A N E N T R E S I D E N T (L a n d e d I m m ig r a n t) o r H a v e y o u liv e d in A lb e rta a ll y o u r life ? IY I N

□ N o te : Include a photocopy o f perm anent resident card.

I f n o , s in c e
^ _ T_ ,

M onth
r_ T_ T_ T_ i

Year
------—

POST-SECONDARY STUDIES
N a m e o f E d u c a tio n a l In s titu tio n : N a m e o f P ro g ra m :

L e n g th o f y o u r p r o g r a m (in y e a r s ) : ____________ C u r r e n t y e a r e n r o lle d in:

Oct 2015

Page 542
 Application Procedure
C o m p le te th e a p p lic a tio n fo rm , a n d in c lu d e th e fo llo w in g :
• a n o ff ic ia l a c a d e m ic tr a n s c rip t,
• a o n e p a g e s u m m a r y o f th e p r o je c t a n d its c o m m e r c ia l p o te n tia l, a n d
• a le tte r o f s u p p o r t fr o m a t le a s t o n e s u p e r v is in g p r o f e s s o r o r in s tru c to r, a n d i f a p p lic a b le a s u p p o r tin g le tte r b y a
s p o n s o r in g c o m p a n y .

V J

f \
Declaration of Applicant
I h a v e r e a d a n d u n d e r s ta n d th e in s tr u c tio n s , a n d d e c la r e th a t:
a. a ll in f o rm a tio n p r o v id e d is tr u e a n d c o m p le te a n d I u n d e r s ta n d it is s u b je c t to a u d it,
b. I w ill b e a f u ll-tim e s tu d e n t a t th e in s titu tio n n a m e d fo r th e p e r io d s ta te d ,
c. I w ill im m e d ia te ly n o tif y S tu d e n t A id A lb e r ta in w r it in g i f I w ith d r a w fr o m f u ll- tim e s tu d ie s b e fo r e
c o m p le tin g o n e s e m e s te r o f s tu d ie s .

I u n d e r s ta n d a n d a g re e th a t:
a. m y p e rs o n a l in f o rm a tio n p e r ta in in g to m y p o s t- s e c o n d a r y a c a d e m ic r e c o r d s m a y b e r e le a s e d a n d e x c h a n g e d b y a n d
b e tw e e n S tu d e n t A id A lb e r ta a n d th e e d u c a tio n a l in s titu tio n fo r th e p u r p o s e o f d e te r m in in g m y e lig ib ility fo r a n a w a rd ,
b. m y p e rs o n a l in f o rm a tio n m a y b e r e le a s e d a n d e x c h a n g e d b y a n d b e tw e e n S tu d e n t A id A lb e r ta a n d a n y p r o v in c ia l
g o v e r n m e n t d e p a r tm e n ts , b o a r d s o r in s titu tio n s to v e r if y th e in f o r m a tio n I h a v e p r o v id e d to S tu d e n t A id A lb e r ta
a n d fo r th e u s e in r e s e a r c h a n d s ta tis tic a l a n a ly s is a n d p r o g r a m e v a lu a tio n , a n d
c. i f I re c e iv e a s c h o la r s h ip m y n a m e , a w a r d a n d c ity /to w n m a y b e r e le a s e d p u b lic ly to p r o m o te th e p r o g r a m , h o w e v e r, th is
is n o t a c r ite r io n fo r e lig ib ility a n d i f 1 d o n o t w a n t to b e id e n tif ie d I w ill c o n ta c t S tu d e n t A id A lb e rta .

Signature of Applicant (in ink) Date (in ink)

V J

Information on other awards is available at:

Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Page 543
 Student Aid Alberta

Charles S. Noble Scholarship

for Study at Harvard

Page 544
 Charles S. Noble Scholarship for Study at Harvard
The Charles S. Noble Scholarship honours Sandy A. Mactaggart, the agricultural entrepreneur, innovator and farm
implement manufacturer who became one of Alberta’s biggest and best grain farmer.

Sandy A. Mactaggart graduated from Harvard and became a highly successful business entrepreneur. Since 1952, he
has been actively involved in the development of properties as well as oil and gas venture capital. Mr. Mactaggart has
established this endowment as a means of expressing his gratitude for an education which has broadened his ability to
enjoy and contribute to life in Alberta. These scholarships recognize and reward academic excellence and provide an
opportunity for outstanding Alberta students to pursue undergraduate studies at Harvard.

Up to three scholarships of $10,000 each

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have
resided in Alberta during the qualifying grades, and
b. intend to apply or be enrolled full-time in an undergraduate program at Harvard.

Selection Procedure
Recipient are selected by the Office of Admissions at Harvard University and their recommendations are forwarded to
Alberta Scholarship Programs.

The award will be disbursed in November after Alberta Scholarship Programs confirms full-time enrollment in post­
secondary studies.

Application Procedure
Mail completed application to:

Office of Financial Aid

Harvard College
86 Brattle Street
Cambridge, MA 02138 USA

For further information contact:

Alberta Scholarship Programs

Telephone: 780 427-8640
Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

Application Deadline: May 15

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage
Scholarship Fund is designed to stimulate the pursuit of excellence by recognizing outstanding achievement
and by encouraging and assisting Albertans to achieve their fullest potential.

Page 545
 Charles S. Noble Scholarship for Study at Harvard
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
ofPrivacy Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
information, please contact Alberta Scholarship Programs, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number (to obtain an ASN go to www.education.gov.ab.ca) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email

M day month year
_L ____ I____ L

CITIZENSHIP (check one)

□ CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Anach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.

ALBERTA RESIDENCY
Do your parents currently live in Alberta?
N

Have you lived in Alberta all your life?

If you have answered “NO” to either of these questions, please include a
” N Since month letter explaining your residency.

POST-SECONDARY STUDIES
Name of Institution Year of Program - Circle One
H A R V A R D 1st 2nd 3 rd 4th

Name of Program: Start Date of Program

i 1 i i i
Month Year

Office Use Only

89 3 2 1 0 8 0 1 1 2
GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

D is b u rs e m e n t

MO YR AUTHORIZATION AWARD KEY APP KEY

Revised: April 2015

Page 546
 Personal Information (continued)

Please indicate if you will be receiving financial assistance and the amount of support expected:

Harvard: ________________________________________________________________________

Other agencies (list): ________________________________________________________________

None: ___________________________________________________

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. 1 will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged by and between Alberta
Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and Harvard University for the purpose of determining my eligibility for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs,
and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

information on other awards is available on studentaid.alberta.ca/scholarships

Page 547
jk

Student Aid Alberta

Dr. Gary McPherson

Leadership Scholarship

Page 548
 Dr. Gary McPherson Leadership Scholarship
Dr. Gary McPherson was a renowned advocate for people with disabilities. He devoted himself to inspiring leadership and
bringing out the best in everyone. He was a member of the Order of Canada, the Alberta Order of Excellence and both the
Edmonton and Alberta Sports Halls of Fame.

This scholarship recognizes students who have demonstrated outstanding leadership, especially in the area of disability,
and/or initiative to improve the conditions and lives of others.

Award Value

100 awards of $2,000 each will be awarded annually.

Eligibility Criteria
Applicants must:
• be a Canadian Citizen or Permanent Resident,
• be currently living in Alberta,
• be enrolled full-time in a post-secondary program: undergraduate, professional, graduate, apprenticeship, diploma
or certificate program at a designated Alberta institution in the year of nomination, and
• have shown outstanding leadership, especially in the area of disability, and/or initiative to improve the lives of
other people while attending a post-secondary institution in Alberta.

Selection Procedure

Each institution will establish a selection committee with appropriate expertise. This committee may be the same as used
for other institutional awards. The committee will consider the role and contribution each applicant has made at their
school. The selection committee may also take into consideration marks, financial need, and other activities as secondary
selection criteria. The Selection Committee will forward the names of the succcessful candidates to Student Aid Alberta
no later than February 15.

Application Procedure

Include with your completed application:

• a resume highlighting your leadership involvement and other activities related to improving the lives of other
people,
• a related letter of reference, and
• an essay of up to a maximum of 1,000 words - please refer to page 4 of the application for details.

f ;
Submit your completed application to the Student Awards Office
\
at your school by the posted application deadline.

Application Deadline: Contact the Student Awards Office.

Page 549
 Dr. Gary McPherson Leadership Scholarship
Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information a n d \
Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award under
the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this information,
V^plcasc contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Return your completed application to the Student Awards Office

Personal Information
Alberta Student Number (go to education.ab.ca to find your ASN or to obtain one) Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdatc Email Address

M
J ____ I____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card. Visa students are not eligible.
ALBERTA RESIDENCY
Do you live in Alberta?
If no, please include a letter indicating where you arc currently living.

POST-SECONDARY STUDIES
Name of Educational Institution

Name of Program: Entry Date of Program

m onth year

Revised: Jan. 2016

Page 550
 Dr. Gary McPherson Leadership Scholarship - Biography

After reading the biography o f Dr. Gary McPherson please attach an essay o f up to a maximum
of 1,000 words using examples of how you have shown leadership, especially in the area of
disability, and/or initiative to improve the lives o f others.

The essay should be typed, double-spaced and use a font size no smaller than a sizelO.

Dr. Gary McPherson Biography

Dr. Gary McPherson was an extraordinary Albertan who sought to improve the conditions and lives of
people through his outstanding leadership ability. Despite being paralyzed due to polio, McPherson was a
sports enthusiast throughout his life and helped to transform wheelchair sports into a worldwide sporting
movement known as the Paralympics.

McPherson was also a leader and advocate for the disabled community serving as Chair o f the Premier's
Council on the Status o f Persons with Disabilities and Vice-Chair o f the Alberta Paraplegic Foundation.
Gary received significant recognition and awards for his achievements including the prestigious Order of
Canada, the Queen's Jubilee Medal and the Alberta Order o f Excellence.

Above all, Gary dedicated his life to his family and to activities that promoted community development
and support for young people. Gary passed away on Saturday, May 8, 2010.

Declaration of Applicant

1 HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to verification;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my post-secondary academic enrollment status may be released and
exchanged by and between Student Aid Alberta and the educational institution for the purpose of determining
my eligibility for a scholarship;
b. personal information may be released and exchanged by and between Student Aid Alberta and any provincial
government departments, boards or institutions to verify the information I have provided to Student Aid
Alberta and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however this is not a criterion for eligibility, and if I do not want to be identified I will contact
Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Page 551
 Student Aid Alberta

Dr. Robert Norman Shaw

Scholarship
 Dr. Robert Norman Shaw Scholarship
This scholarship is named in honour of Dr. Robert Norman Shaw, a pioneer in the Sexsmith area. Dr. Shaw is remembered for his
contributions to the community as a doctor, engineer, veterinarian and coroner..

The Dr. Robert Norman Shaw scholarship recognizes and rewards the exceptional academic achievement of a student graduating
from Sexsmith Secondary School and who is entering post-secondary studies in a health related field.

One award of $1,500.

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Sexsmith Secondary School after September 1, 1996,
c. plan to enroll or be enrolled full-time in a post-secondary program related to health, and
d. demonstrate a high academic standing in Grade 12.

Selection Procedure
Recipients will be selected based on the highest average marks obtained in five eligible Grade 12 courses:
One of: English 30, 30-1 or 30-2, or Francais 30, or 30-2
At least four the following Grade 12 courses:
Mathematics 30-1 Mathematics 30-2
Science 30 Biology 30
Chemistry 30 Physics 30
Social Studies 30, 30-1 or 30-2 A language other then one listed above

Application Procedure
Submit completed application form to Student Aid Alberta. Students will be notified of the status of their application
in September and the awards are issued in November after Student Aid Alberta confirms full-time enrolment
of successful candidates:
Mail to: Courier to:
Student Aid Alberta Student Aid Alberta
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K.2V1

Telephone: 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting
Albertans to achieve their fullest potential.

Application Deadline: June 1

Page 553
 Dr. Robert Norman Shaw Scholarship

Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the
Freedom of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility
for an award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/To\vn

Previous Surname
Province Country Postal Code Area Code felephone Number

Gender (circle one) Date of Birth Email

M F day 1 month 1 year
__ L__1___ 1___1___1__L__ 1__
CITIZENSHIP (check one)
CANADIAN CITIZEN or I I PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____ 1____ ____ 1____ 1____ 1____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? |___| Yes, what year
□ No

Are you a student at Sexsmith Secondary School? N

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academ c End L)ate

month 1 year month I year
____ 1____ ____ 1____ 1____ 1____
Institution City Length of Program Year of Program
1st 2nd 3rd 4th

Page 554
 Declaration of Applicant
I have read and understand the instructions, and declare that:
a. All information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I understand and agree that:

a. My personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Student Aid Alberta for the purpose of determining my eligibility for a scholarship,
b. My personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Student Aid Alberta and the educational institution for the purpose of determining my eligibility for a scholarship,
c. My personal information may be released and exchanged by and between Alberta Innovation and Advanced Education and
any provincial government departments, boards or institutions to verify the information I have provided to Alberta Innovation
and Advanced Education, and for the use in research and statistical analysis in program evaluation.

I understand and agree that:

If I receive a scholarship my name, award and hometown may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if I do not want to be identified, I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
If your institution code is not listed here, see list of Publicly Funded Institutions.

University of Alberta.................... ...2201
University of Calgary................... ...2202
University of Lethbridge.............. ...2203
NAIT............................................. ...2221
SAIT............................................. ...2222
Alberta College of Art & Design... ...5110
Ambrose University..................... ...9041
Athabasca University.................... ...2204
Bow Valley College...................... ...2218
Concordia University College (AB)..2246
Devry Institute of Technology...... ....2040
Grande Prairie Regional College... ....2241
Grant MacEwan University.......... ....2247
Keyano College............................ ....2230
Kings University College............. ....2255
Lakeland College.......................... ....2225
Lethbridge College....................... ....2220
Medicine Hat College................... ....2242
Mount Royal University........ ......... 2243
Northern Lakes College......... .........2020
Norquest College................... ......... 2226
Olds College.......................... ......... 2224
Portage College...................... ......... 2219
Red Deer College................... .........2244
St. Mary’s ............................... .........5661

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 555
 Student Aid Alberta

Earl and Countess of Wessex

World Championships in
Athletics Scholarship
 Earl and Countess of Wessex:
World Championships in Athletics Scholarship

The Earl and Countess of Wessex - Edmonton 2001 World Championships in Athletics Scholarship was established by the Government of
Alberta to commemorate the visit of Their Royal Highnesses The Earl and Countess of Wessex to the 8th International Association of
Athletic Federations (IAAF) World Championships in Athletics.

This scholarship recognizes the top male and top female Alberta students who have excelled in track and field, have a strong academic
record and plan to continue their studies at the post-secondary level in Alberta.

Two awards of S3,000 are awarded yearly.

Eligibility Criteria

Applicants must
a. be a Canadian citizen or permanent resident,
b. be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the qualifying year,
c. plan on entering full-time post-secondary studies at the University of Alberta, the University of Calgary or the University
of Lethbridge and must join the Track and Field team at that institution within one year,
d. have completed Grade 12 in Alberta in the same year that they apply for the scholarship, and
e. have met the entrance requirements to be accepted at either institution.

Selection Procedure

Selection will be based on a student’s placement in provincial and national championships, Alberta Athlete Development Program
(AADP) standards, best performances, Mercier score and a written recommendation from the applicant’s coach. Recipients will be
chosen by a selection committee with representation from Athletics Alberta and from each of the varsity track and field programs in
Alberta.

Application Procedure

Applications are also available from high school counsellors. Applicants will be notified of the result of their application in December.
The award will be issued in January after Student Aid Alberta confirms the recipients’ full-time enrolment.

Faxed applications are not accepted.

Mail to: Courier to:
Student Aid Alberta Student Aid Alberta
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1
Contact: Student Aid Alberta Service Centre at 1-855-606-2096
Visit: studentaid.alberta.ca/scholarships

Alberta Scholarships
Alberta Scholarships including the Alberta Heritage Scholarship fund and the Achievement Scholarship Program, were designed to
stimulate the pursuit of excellence by rewarding outstanding achievement.

Application Deadline is October 1

Page 557
 Earl and Countess Of Wessex: Edmonton 2001 World
Championships In Athletics Scholarship
Innovation and Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom
of Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an award
under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the collection of this
information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
You may use the Learner Registry at www.education.gov.ab.ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number required for processing) Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mail inti Address (Include ADt. or Box Number) Citv/Town

Previous Surname
Provinc e Countr V Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M J___ I___ L
day month year

CITIZENSHIP (check one)

J CANADIAN CITIZEN or [___PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Did your parents live in Alberta while you were in high school
N N
Have you lived in Alberta all your life?
IF YOU ANSWERED “NO” TO EITHER OF THESE QUESTIONS PLEASE
N Since INCLUDE A LETTER EXPLAINING YOUR RESIDENCY.
_L J___ I___ L
month year

PROPOSED POST-SECONDARY STUDIES

Name of Institution Institution Code

Location Start Date of Program

_L J___ I___ L
month year

Institution Codes:
University of Alberta 2201 University of Calgary 2202 University of Lethbridge 2203

Office Use Only

Revised: Oct 2015

Page 558
High School Information:
Name of high school you are you attending for Grade 12:
Year you will graduate from high school?

Athletic Information:
Sport _________________________________________ Athletics Alberta registration number __________________________
Will you be joining the Track and Field Team at the post-secondary institution you will be attending? (circle) Yes or No

Name of coach who will be completing the attached reference form _________________________________________________

Attach a list of your Track and Field accomplishments to date: name of event, placing, and any other relevant details.
State your personal best performances and provincial high school championships placing for your best event(s).

Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. personal information pertaining to my high school academic record may be released and exchanged
by and between Student Aid Alberta for the purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may be released
and exchanged by and between Student Aid Alberta and the educational institution for the purpose of
determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Student Aid Alberta and any
provincial government departments, boards or institutions to verify the information I have provided to
Student Aid Alberta, and for the use in research and statistical analysis in program evaluation.
I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Have you answered all questions?

Your application may be delayed if information is missing.

Page 559
 Reference Form

Earl and C ou ntess O f W essex: E dm onton 2001 W orld C ham p ion ship s
in A th letics S cho larsh ip

Instruction to Coach

Since there is a large number o f qualified candidates competing for a limited number o f awards, we would like
to ensure the most deserving individuals are identified; and appreciate your cooperation in rating this
candidate.

You may submit a typed letter commenting on the areas listed below or complete the form on the next page.
If submitting a separate letter, please indicate your professional relationship to the candidate and ensure that
you clearly state the name o f the applicant and the name o f the award.

Your comments should be as precise as possible. For example, state a comparison group, its size, and the
applicant’s rank in that group. Your appraisal should include an evaluation o f the candidate in the following
areas:
-general athletic skills
-skills specific to their sport
-dedication, and
-general scholastic performance

Your prompt attention to the candidate’s request to provide this reference is important. Without a reference,
the candidate will not be considered for this scholarship. Your comments are received in confidence.

Reference letters must be returned by October 1 to:

Mail to: Courier to:

Student Aid Alberta Student Aid Alberta
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1

Page 560
 Earl and C ountess o f W essex: E dm onton 2001 W orld C ham p ion ship s
in A th letics S cho larsh ip

Reference for: _______________________________________________________________________

Name of Applicant

NOTE TO COACH: Please print legibly in dark ink. Our office will be photocopying this form,

a) Briefly define your professional relationship to the candidate (including how long you have known the applicant).

b) Assessment (should extra space be required please attach another page).

General athletic skills:

Skills specific to their sport:

Dedication:

General scholastic performance:

General comments, including placing at events (use additional pages if required).

Name of Coach Number of years coaching

Current School Number of athletes coached

Signature of Coach Date Business Phone

Page 561
 Student Aid Alberta

Janet and Horace Allen

Science Scholarship

Page 562
 Janet and Horace Allen Science Scholarship
This scholarship was established by the family of Janet and Horace Allen through the Alberta Heritage Scholarship Fund Endowment
program.

The scholarship recognizes the academic excellence of a student from Crowsnest Pass High School for their accomplishements in the
sciences.

Award Value - $1,500

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or permanent resident and be an Alberta resident - the applicant’s parent(s) must have resided in
Alberta during the qualifying grades,
b. have graduated from Crowsnest Pass High School after September 1, 1995,
c. be enrolled or planning to enroll full-time in a post-secondary program, and
d. have the highest average of the eligible courses in Grade 12.
Biology 30 Chemistry 30
Physics 30 Science 30

Selection Procedure
The applicant with the highest average in two of the following Grade 12 courses will receive the award:

Application Procedure

Submit completed application form to Alberta Scholarship Programs.

Students will be notified of the status of their application in September and the awards are issued in November after Alberta
Scholarship Programs confirms full-time enrolment of the successful candidates.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

The Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans to
achieve their fullest potential.

Application Deadline: June 1

Page 563
 Janet and Horace Allen Science Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal nam e) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt, or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Teleiphone Number

Gender (circle one) Date of Birth Email Address

M F <jay | rn^nlh | [ yepr ^

CITIZENSHIP (check one)

CANADIAN CITIZEN or PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? I f ‘NO' since
Y N Y N month year
____ 1____ ____ 1____ 1____ 1____
If you have answered “NO” to one of the Alberta Residency questions, please include a letter explaining your residency.

Have you applied for an Alexander Rutherford Scholarship? |] Yes, what year □ No

Are you a student at Crowsnest Pass High School?

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Page 564
 Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies before
completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by and
between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility for a
scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any provincial
government departments, boards or institutions to verify the information I have provided to Alberta Scholarship Programs, and
for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is not a
criterion for eligibility, and if 1 do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes
If your institution code is not listed here, see list of Publicly Funded Institutions.

University of Alberta.................... ...2201
University of Calgary................... ...2202
University of Lethbridge.............. ...2203
NAIT....' ................... .7.............. ...2221
SAIT............................................. ...2222
Alberta College of Art & Design... ...5110
Ambrose University..................... ...9041
Athabasca University.................... ...2204
Bow Valley College...................... ...2218
Concordia University College (AB). .2246
Devry Institute of Technology......... .2040
Grande Prairie Regional College..... .2241
Grant MacEwan University............ .2247
Keyano College............................... .2230
Kings University College..................2255
Lakeland College............................. .2225
Lethbridge College.......................... .2220
Medicine Hat College...................... .2242
Mount Royal University........ ......... 2243
Northern Lakes College......... .........2020
Norqucst College................... ......... 2226
Olds College.......................... .........2224
Portage College...................... .........2219
Red Deer College................... .........2244
St. Mary’s............................... .........5661

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 565
 M he^ n Student Aid Alberta

Keyera Energy
Peter J. Renton Memorial
Scholarship

Page 566
 Keyera Energy
Peter J. Renton Memorial Scholarship
Established in memory of Peter J. Renton who, during a career in the energy sector that spanned 40 years, recognized that
environmental protection, social responsibility and a competent and experienced workforce are essential components of a successful
business. He also believed in life long learning that builds upon education and experience.

The scholarship is intended to assist and encourage Alberta students to pursue full-time studies in a post-secondary program in a field
related to the oil and gas industry.

Award Value
Maximum value is S6,000 - $3,000 for first year of study and $3,000 in the second year providing the recipient remains in good
standing and continues into the second year of their program with a minimum course load of three courses per semester.

Eligibility Criteria
Applicants must:
• be a Canadian Citizen or permanent resident,
• be an Alberta resident - the applicant or the applicant’s parent(s) must have resided in Alberta during the qualifying grades,
• have completed the requirements for high school graduation in Alberta, and
• plan to enroll full-time in an accredited Alberta post-secondary institution in the first year of a degree or diploma program in
a field of study supporting the oil and gas industry, including but not limited to: business, communications, sciences and
engineering, technical programs, information technology and the trades.
Note: Family of Keyera Energy employess are eligible to apply.
Relatives of the selection committee members are not eligible.

Selection Procedure

A selection committee established on behalf of Keyera Energy and Alberta Scholarship Programs will select an award recipient based
on a combination of community service, employment, athletics, leadership, and/or academic achievement.

Application Procedure
Submit a completed application during your last year of high school and include with your application the following:
• References:
*One reference from the School Principal or school representative.
*Two other references, ideally one reference from a teacher, counselor or coach, and one other reference from someone who
is not connected with the school, e.g. employer, mentor, representative from volunteer organization.
• Your answers to the questions in Part 2 of the application., and
• A typed statement in Part 3 of the application on how you would compare your personality and characteristics to those of
Peter J. Renton.

Application deadline is May 1.

Mail: Courier:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB T5K 2V1

Page 567
 Keyera Energy
Peter J. Renton Memorial Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor-9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Please review your application to ensure you have completed all the required fields.
Missing information may cause delay in processing your application.

Part 1 - Personal Information

Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Num ber) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Birthdate Email Address

M
J ____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Did you or your parent)s) live in Alberta during your Grade 12 school years?
If no, please include a letter indicating where you or your parent(s) lived during your Grade 12.

PROPOSED POST-SECONDARY STUDIES (Indicate first choice)

Name of Educational Institution Institution Code (See the last page for institution codes)

Name of Program: Entry Date of Program

___I__ J ___ I___ L

month year

Revised April 2015

Page 568
 SECONDARY EDUCATION
Name of High School: ------------------------------

Town/City: ---------------------------------------------

Date of Completion of High School (month/year):

Part 2

On a separate sheet, in 150 words or less, double spaced, use a font size no smaller
than 10, please provide your answers to the following questions.

1. What are your plans after high school?

2. What subjects do you enjoy at school and why?

3. What area do you plan to study? How does this area complement the oil and gas industry?

4. What are your favourite activities inside and outside o f school?

Are you involved in any organizations,volunteer projects, sports, employment, or hobbies?
List up to 5 areas o f involvement, indicating your level and time of involvement.

5. What do you consider your best qualities/attributes?

6. What do you consider your best accomplishments?

7. How did you first hear about the Peter J. Renton Memorial Scholarship?

The Alberta Heritage Scholarship Fund

The Alexander Rutherford Scholarship is funded through the Alberta Heritage Scholarship Fund. This program was created by a
SI 00 million endowment from the Alberta Heritage Savings Trust Fund and is designed to stimulate the pursuit of excellence by
rewarding outstanding achievement and assisting Albertans to achieve their fullest potential.

Page 569
 Part 3
Peter J. Renton Memorial Scholarship
Biography

After reading the biography of Peter J. Renton, how do you compare your personality and charactersistics
to his? Please provide examples in a typewritten statement of no more than 300 words.

Candidates should reflect on Peter's example of integrity, humour, leadership and diverse interests when
they complete their application.

People who worked with Peter throughout his 40-year career in the energy sector immediately recall his integrity,
humour, commitment to fair play, and most of all, his resolve to "do the job right." A man of wide interests and
infectious curiosity, he approached every task and every relationship with a passion. Tenacious when he believed in
someone or something, he never let an obstacle deter him from doing what needed to be done. He valued honesty
more than anything and believed that integrity is the cornerstone of both personal and business dealings. A serious
and accomplished professional, he loved to laugh and took great delight at seeing the funny side of things. He loved
time with his family and friends, golf, sports cars and other interests too numerous to mention. In short, he was an
inquisitive, multidimensional man.

Peter's career spanned many aspects of the oil and gas industry. After graduating from Mechanical Engineering at
the University of Calgary, he began his career in Argentina with an oil and gas service company. Returning to
Canada, he joined Gulf Canada Resources where he worked for 25 years in a variety of roles, including oil and gas
production, natural gas processing, and natural gas liquids marketing. This diverse experience was the basis for the
insight and knowledge that Peter happily shared with co-workers. In 1998, Peter was a member of the management
group that left Gulf Canada to form Keyera Energy's predecessor company Gulf Midstream Services. Over the next
ten years, he was a key contributor to Keyera's success.

Peter recognized that environmental protection, social responsibility and a competent and experienced workforce are
essential components of a successful business and, in 2003, he assumed responsibility for these elements at Keyera.
His commitment to "doing the right thing" in all aspects of business led Peter to build protocols and systems that to
this day help Keyera balance diverse stakeholder expectations, respect the environment and promote the health and
safety of employees and the communities in which they work.

Peter believed in life-long learning that builds upon education and experience. Combined with his drive to promote
safe, efficient and reliable operations, this led him to seek ways to engage employees in on-going skills upgrading
and certification. In addition to sharing his experience and vision, he was instrumental in the development of
Keyera's innovative Competency Management and Development System. This important program is now used by
many companies throughout the Canadian oil and gas sector.

As a mentor, Peter was quick to recognize the potential in others. He took great pleasure in asking questions,
sharing his knowledge, and in reinforcing behaviour that leads to success. Many people working in oil and gas
credit Peter with providing them the opportunity to develop their talents and skills and reach their full potential.

Peter's legacy of commitment and actions continues to benefit Keyera today. This scholarship was created to
commemorate this legacy by assisting individuals with similar characteristics to pursue a post secondary education
leading to a career in the oil and gas industry.

Page 570
 Part 4
Peter J. Renton Memorial Scholarship
References

You must submit three references to Alberta Scholarship Programs:

1. One reference must be from the School Principal or school representative.

2. Two other references ideally one reference from a teacher, counselor or coach, and one other reference from
someone who is not connected with the school, e.g. employer, mentor, representative from volunteer organization.
Please select individuals who know you well so they might comment not only on your academic abilities but also on
your qualities of character, attitudes, and social adaptability. If you have only recently joined your present school,
one of the teacher recommendations may come from your previous school.

Please list the names of your references here:

Name of School Principal or representative:

Name of individual completing a general reference (1): __

Name of individual completing a general reference (2):

School Principal

This student has applied for Peter J. Renton Memorial Scholarship. The scholarship was created to commemorate the
legacy of Peter J. Renton by assisting individuals with similar characteristics to pursue post secondary education leading to a
career in the oil and gas industry. Candidates and their principals should reflect on Peter's biography and his example of
integrity, humour, leadership and diverse interests when they complete their applications.

The Scholarship Selection Committee would greatly appreciate your comments on this applicant. If two or more candidates
are applying from one school, the selection committee asks that you provide an indication of the school's first choice

Please comment on both the strengths and weaknesses of the candidate and mail to the address below. Do not return your
comments to the student or his/her parents/guardians.

The deadline for receipt of your reference is May 1. Scanned references are accepted.

General Reference

The Scholarship Committee would greatly appreciate your comments on this applicant. Your frank assessment is
invaluable. All student evaluations are handled in strict confidence.

Please include a letter commenting on both the strengths and weaknesses of the candidate and send to the address below.
Do not return your comments to the student or his/her parents/guardians.

The deadline for receipt of your reference is May 1. Scanned references are accepted.

Mail references to: Courier or Deliver references to: Email: scholarships@gov.ab.ca

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB T5K2V1
Page 571
 Part 5 - Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from
full-time studies before completing one semester of studies.
I UNDERSTAND AND AGREE THAT:
a. personal information pertaining to my high school academic record may be released and exchanged by
and between Alberta Education and Alberta Scholarship Programs for the purpose of determining my
eligibility for a scholarship;
b. personal information pertaining to my post-secondary academic enrollment status may be released and
exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for a scholarship;
c. personal information may be released and exchanged by and between Alberta Scholarship Programs
and any provincial government departments, boards or institutions to verify the information I have
provided to Alberta Scholarship Programs, and for the use in research and statistical analysis in
program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Institution Codes

University of Alberta....................... 2201
University of Calgary...................... 2202
University of Lethbridge.................. 2203
NAIT................................................ 2221
SAIT................................................ 2222
Alberta College of Art & Design.....5110
Ambrose University College........... 9041
Athabasca University....................... 2204
Banff Centre..................................... 2227
Bow Valley College......................... 2218
Concordia University College (AB)..2246
Devry Institute of Technology.......... 2040
Grande Prairie Regional College...... 2241
Grant MacEwan University.............. 2247
Keyano College................................ 2230
Kings University College................. 2255
Lakeland College.............................. 2225
Lethbridge College........................... 2220
Medicine Hat College...................... 2242
Mount Royal University.................. 2243
Northern Lakes College................... 2020
Norquest College............................. 2226
Olds College.................................... 2224
Portage College................................ 2219
Red Deer College............................. 2244
St. Mary’s University College......... 5661
Taylor University............................. 2268

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 572
 Student Aid Alberta

Persons Case
Scholarship

Page 573
 Persons Case Scholarship
The Persons Case Scholarship was established in 1979 to commemorate the 50th anniversary of the ‘Persons Case'.
The scholarship is jointly administered by Alberta Advanced Education and Alberta Human Services. It honours the efforts of five
Alberta women: Emily Murphy, Louise McKinney, Nellie McClung, Irene Parlby, and Henrietta Muir Edwards who fought and won
the right for the women of Canada to be officially deemed ‘persons’ under the law.

Award Value - $1,000 to $5,000

Eligibility Criteria
Applicants must be:
• a Canadian Citizen or a Permanent Resident and be an Alberta resident, and
• a full-time student in the current academic year (August 1 to July 31) at an Alberta post-secondary institution approved
by Alberta Advanced Education. Consideration will be given to undergraduate students studying out-of-province, however,
they must identify the special nature of the out-of-province program. Students pursuing graduate studies out-of-province
will be given full consideration.

Selection Procedure
The Selection Committee will consider an applicant’s program of studies, academic achievement and personal essay.
Students whose studies will ultimately contribute to the advancement of women, or who are studying in fields where members of
their gender are traditionally few in number are encouraged to apply.
Students entering the second or subsequent year of their program and who were selected to receive a scholarship generally had a
GPA of 3.0 or greater. Approximately thirty to forty recipients are selected for a total budget of $ 100,000.

Application Procedure
Submit with the application:
• an official transcript of all post-secondary studies, and an essay outlining why the issues you are studying
are important to you and how your studies, activities and community involvement contribute to the advancement of
women, and
• a curriculum vitae/resume including your volunteer experience, scholarships received and amount awarded.

Faxed applications are not accepted.

Student Aid Alberta no longer accepts scholarship applications dropped off in person.

Mail to:
Student Aid Alberta
Box 28000 Station Main
Edmonton, Alberta T5J 4R4

Contact: Student Aid Alberta Service Centre at 1-855-606-2096

Visit: studentaid.alberta.ca/scholarships

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund. The Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by rewarding outstanding achievement and encouraging Albertans to achieve their
fullest potential.

Application deadline is September 30

Page 574
 Persons Case Scholarship

Advanced Education is collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy1Act (FOIP Act), as being directly related to and necessary to determine your eligibility for an
award under the Alberta Heritage Scholarship Act and to administer Alberta Scholarships. If you have any questions about the
collection of this information, please contact Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4.

Personal Information
You may use the Learner Registry at cducation.gov.ab.ca to find your Alberta Student Number or to have one assigned.

Alberta Student Number (required for processing) Social Insurance Number (required for processing)

Surname Given Name anc Middle Initial

Mailing Address (include Apt. or Box Number) City/Town

CITIZENSHIP (check one) *ALBERTA RESIDENCY

CANADIAN CITIZEN OR Y N Do your parents currently live in Alberta (circle one)

PERMANENT RESIDENT (Landed Immigrant) Y N Have you lived in Alberta all your life? (circle one)
Note: Include a photocopy of permanent resident card.
Visa students are not eligible. If no, since , | ,
month year

Gender (circle one) Birthdate (Day, M onth, Year)______ Email

M F
___l___ ___I___ ___I___ I___ I___

*If your parents do not currently reside in Alberta AND you have not lived in Alberta all your life,
please include a letter explaining the time spent in Alberta as a non full-time student.

Application deadline is September 30

Office Use Only

Revised:Jan 2016

Page 575
 Education Information

Which institution will you attend this fall What program will you be enrolled in

What year of study will you be enrolled in?

H 1st | 12nd I 3rd | 14th | | Other
What is the length of your program?
] 1 Yr. Q 2 Yrs. 3 Yrs. Q 4 Yrs. Q Other
What degree or diploma will you graduate with? When will you complete the program?

J ____ L
month year
What is your desired occupation?

Education Record
Please list the last three schools, colleges or universities that you attended.
(If you have attended more than three schools, you may include the information on a separate resume)

Period of Study Educational Institution

From To Name of Institution Program

Essay Question
Use no more than a 1,000 words (include a word count); double spaced, with a font size of 12 and do not type on both sides of the
page.
The essay is a significant component o f the application and selection. Therefore, it is critical to elaborate on the following:
*describe how your studies, activities and community involvement contribute to the advancement of women, and
provide details of the extent and level of your involvement in these areas (include a resume), and
*give a brief explanation why the program of study you chose is important to you.
If enrolled in a non-traditional program, please provide some detail on the program.

Helpful Hints
Incomplete applications will not be submitted to the selection committe. To ensure your application is reviewed by the selection
committee make sure you have:
□ answered all questions,
□ included your essay,
□ attached a resume, and
□ attached original transcripts from all post-secondary studies.

Notification of the results may be expected in December.

Page 576
 Declaration of Applicant

I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:

a. all information provided is true and complete and I understand it is subject to

verification;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify Student Aid Alberta in writing if I withdraw from full-time
studies before completing one semester o f studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my post-secondary academic progress and
enrolment status may be released and exchanged by and between Student Aid Alberta
and the educational institution for the purpose o f determining my eligibility for a
scholarship;
b. my personal information may be released and exchanged by and between Student Aid Alberta
and any provincial government departments, boards or institutions to verify the information I
have provided to Student Aid Alberta, and for the use in research and statistical analysis in
program evaluation.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want
to be identified, I will contact Student Aid Alberta.

Signature of Applicant (in ink) Today’s Date (in ink)

Please indicate how you heard about the Persons Case Scholarship (check more than one if applicable):

H Student Aid Alberta website EH School/College counsellor at

0 Scholarship Brochure EH Friends
1 I Family □ Other ________________

Further information on other awards is available on studentaid.alberta.ca/scholarships

Page 577
 Student Aid Alberta

Theodore R. Campbell
Scholarship

Page 578
 Theodore R. Campbell Scholarship
The Theodore R. Campbell Scholarship recognizes the academic excellence of an aboriginal student enrolled in an education
program at Blue Quills First Nations College. The scholarship was established by the Theodore R. Campbell family through the
Alberta Heritage Scholarship Fund Endowment program.

Award Value - $1,500

Eligibility Criteria
An applicant must:

• be First Nations, Inuit, or Metis and a Canadian Citizen or Permanent Resident,

• be an Alberta resident and to be considred an Alberta resident one of the following conditions must apply:
*one parent must currently be residing in Alberta, or
*Alberta is the last place you have lived for twelve (12) consecutive months before being a full-time student, or
*you are marrried to an Alberta resident before the start of your qualifying year of study,
• have completed the first year of an Education degree (university transfer) at Blue Quills First Nations College,
• have completed a minimum of 24 credits in the first year and obtained passing marks in all courses with at least
a 70% attendance record,
• not be sponsored for their studies,
• demonstrate financial need, and
• be continuing full-time in the second year of the program.

Application Procedure

Application forms are available from the Office of the Registrar at Blue Quills First Nations College. The recipient is selected
by the Office of the Registrar.

Return the completed application to:

Office of the Registrar

Blue Quills First Nations College
Box 279
St. Paul, AB TOA 3A0

Application Deadline: June 1

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 579
 Theodore R. Campbell Scholarship
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number (go to www.education.gov.ab.ca to fin d your A S N or to have one assigned)Social Insurance Number (required for processing)

Last Name (c u rre n t f u ll leg a l nam e) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll leg a l nam e)

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M
J ____ I____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
N o te : Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY

month year

POST-SECONDARY STUDIES - 2013-2014 Academic Year

Name of Institution Name of Program

L o c a t i o n ( I f o u tsid e A lb e rta , please p ro v id e co m p le te address.) Length of Program Year of Program

Number of years
□1st □2nd □3rd □4th
I am enrolled in a University transfer program: Academic Year Ends
] Yes ] No ____i____ ____ i____ i____ l____ ____i____ ____ i____ i____ i____
month year month year

Please indicate your aboriginal status: Treaty, Non-Status, C31, Metis or Inuit:

Office Use Only

Revised: April 2015

Page 580
 Education Record
Please list the last three schools, colleges or universities that you attended. If you have attended more
than three educational institutions you may include the information on a separate page.

PERIOD OF STUDY INSTITUTION

From (mm/yy) To (mm/yy) Name of Institution Program

Financial Information
Marital Status: Married____Single ____ Single Parent ____ Number of dependents living with you:

MONTHLY EXPENSES (while in school) MONTHLY INCOME (income while in school)

Rent/Mortgage payment Wages/Salary after deductions

Utilities (power, water, telephone, heating) Spousal/Partner income after deductions

Food/Clothing/Personal Care Contribution from parents

Transportation Child Support/alimony

Child care/Babysitting Government Funding: indicate source:

Additional expenses (i.e. medical)
Other Income (indicate source)
List

Total Monthly Expemses Total Monthly Income

Total Monthly Income X number

Total Monthly Expenses X number of months in school (D)
of months in school (A)

EDUCATION EXPENSES (Include if not covered by sponsorship)

Tuition OTHER RESOURCES

Fees Savings when you start school

Books/Supplies/Instruments Other funding ie. grants, scholarships

(excluding loans and lines of credit)
Total Educational Expenses (B) List:

Total Other Resources (E)

Add together monthly and educational
expenses (A + B) = (C) Add together monthly and Other
Resources (D + E) = (F)
ASSETS Value
Calculated Need:
Registered Retirement Savings Plan
Total Expenses (C)____________
Assets (i.e. term deposits, bonds, stocks)
Minus Total Resources (F )___________ = Total Need

Total Assets

Page 581
 Declaration of Applicant
I have read and understand the instructions, and declare that
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from
full-time studies before completing one semester of studies.

I understand and agree that

a. my personal information pertaining to my post-secondary academic record and enrolment status may
be released and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the information
I have provided to Alberta Scholarship Programs, and for the use in research and statistical analysis in
program evaluation, ester of studies.
I UNDERSTAND AND AGREE THAT:
if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Alberta Heritage Scholarship Fund

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve the fullest potential.

Have You Answered All Questions?

Your application will be delayed if information is missing.

Information on other awards and scholarships is available on studentaid.alberta.ca/scholarships

Page 582
 Student Aid Alberta

Tiessen Foundation
Broadcast Scholarship

Page 583
 Tiessen Foundation Broadcast Scholarship

This award was created to recognize an outstanding Alberta high school student and to encourage and assist students with the pursuit
of post-secondary studies at a broadcast institution in Canada.

Award Value - $750

Eligibility Criteria
Applicants must:
a. be a Canadian citizen or a Permanent Resident,
b. be an Alberta resident - the applicant’s parent(s) must have resided in Alberta during the qualifying grades,
c. have completed Grade 12 at an Alberta high school, and,
d. plan to enroll or be enrolled full-time at any recognized post-secondary institution in Canada that offers degree or diploma
programs in broadcasting such as TV, radio, broadcast engineering

Students should apply in the year they graduate from high school. Students may only apply once for this award.

Application Procedure
Application forms are available from high school counsellors and Alberta Scholarship Programs.

Applicant must:
* complete an application form,
* include a maximum 750 word essay outlining their interest and pursuit in the field of broadcasting, and
* attach a letter of support from a teacher.

Selection Criteria

A selection committee established by the Tiessen Foundation will select the recipients.

Applicants will be short-listed based on their Grade 12 academic average using the Alexander Rutherford Scholarship criteria.
Copies of the top ten applications will be forwarded to the selection committee who will review the applications and select the
recipient based on the application, essay and letter of support.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 7th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K 2V1

Telephone: 780 427-8640

Email: scholarships@gov.ab.ca
Visit: studentaid.alberta.ca/scholarships

Application Deadline: June 1

Page 584
 Tiessen Foundation Broadcast Scholarship
We are collecting the personal information upon this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required fo r processing)

Last Name (c u rre n t fu ll leg a l n am e) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll leg a l nam e)

Mailing Address (In c lu d e A p t, o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email

M djiy | mopth | ( ye.y ,

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
N o te : Anach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
____ 1____ ____ 1____ 1____ 1____
I f y ou h av e a n sw e re d “ N O ” to one o f th e A lb e rta R e sid en c y q u e stio n s , p lea se in c lu d e a le tte r e x p la in in g th e tim e s p e n t in A lb e rta
as a n o n fu ll-tim e s tu d e n t.

Name of high school you graduated from: __________________________________________________

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month | year month | year
____i____ ____ i__ _ i ____ i____ _ l ____ I____ I____ l____ L

Institution City Length of Program Year of Program

y 2nd 3rd

Page 585
 Essay

Include with your application, a maximum 750 word essay outlining your
interest and pursuit in the field of broadcasting. It can also include any
work or volunteer experience in the field of broadcasting.

Note: Please include a letter of support from a teacher.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by
and between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility
for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any
provincial government departments, boards or institutions to verify the information I have provided to Alberta
Scholarship Programs and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Information on other awards is available on studentaid.alberta.ca/scholarships

Page 586
 Student Aid Alberta Indigenous Careers Award
Award Value - $2,000 per semester

The Indigenous Careers Award is designed to encourage Indigenous Albertans (First Nations, Metis, and Inuit) to pursue and complete post­
secondary studies in certificate, diploma, applied degree, and bachelor’s degree programs that lead to high-demand career outcomes in Alberta.

Indigenous Ancestry and Residency Requirements Eligible Programs of Study

You must be Status Indian/First Nations, Non-Status Indian/
First Nations, Metis, or Inuit and be able to provide proof of
Indigenous ancestry.
You must be a Canadian Citizen or Permanent Resident
of Canada and an Alberta resident.
Eligible School Requirement
You must be attending a participating:
• public post-secondary school in Alberta, or
• First Nations College in Alberta
Course Load and Study Requirements
You must be enrolled in the 2015-16 winter semester
in order to be considered for these awards.
You must be enrolled in at least 60% of a full course load.
If you are a student with a documented permanent disability,
you can be eligible if you are enrolled in at least 40% of a full
course load.
Your school determines what constitutes a full-time course
load in each program.
Co-op students, students in brokered programs, and students
who are participating in an official exchange may be eligible.
You must be in satisfactory academic standing as determined
by your school - satisfactory academic standing may vary in
how it is determined by school or program.
You are not eligible to receive the award if you:
- switch your program of study from an eligible program
to an ineligible program before the award is paid, or
- withdraw from studies or drop from full-time to part-time
studies before the award is paid.
Credential Types
You must be enrolled in a certificate, diploma, applied or
bachelor’s degree program. Students enrolled in apprenticeship
technical training, integrated training, pre-employment or
non-credential programs are not eligible.
University transfer programs are only eligible if they are
in the program bands described in the right hand-column.
E.g. General university transfer programs would not be
eligible but an education transfer program that leads directly
to a Bachelor of Education program would be eligible.
Eligible program bands are based on Government of Alberta’s
forecast of high-demand careers in Alberta. The program
bands are:
• Business
• Education
• Physical, Natural & Applied Sciences
• Technologists
Programs that fall within these program bands are eligible
if they lead to careers in the following:
- Finance
- Accounting
- Marketing
- Business administration and management
- Communications technologists and technicians
- Elementary and secondary teaching
- Teaching related fields
- Early childhood education and childcare
- Natural resources and conservation
- Engineering and engineering-related fields
- Computer and information sciences
- Agriculture
- Architecture and urban planning
- Biological sciences
- Physical sciences
- Mathematics and statistics
- Science technologists and technicians
- Mechanic and repair technologists and technicians
- Precision production
Program Bands Not Eligible
The following program bands are not eligible:
• Health Sciences
• Languages, Social Sciences, Arts & Humanities
• Legal & Security
Other Eligibility Criteria (if required)
(Schools may insert any additional eligibility requirements.)

How to Apply

You must apply to the school you are attending.

If you are a co-op student, a student in a brokered program,
or participating in an official exchange, you must apply through
the school that will issue your post-secondary credential.

Page 587
^ ( { h e r b f iji insert school Name or Logo Indigenous Careers Award
S tudent A id A lb erta

FOIP Collection Notice or Personal Information Protection Act (PIPA) Notice

(Schools must provide FOIP or PIPA collection notices, as required.

Indigenous Ancestry

Please indicate your Indigenous Ancestry:

□ Status Indian/First Nations □ Non-Status Indian/First Nations □ Metis □ Inuit

Documentation Requirements: You must provide proof of your Indigenous ancestry to your school to determine your eligibility.
Acceptable documents of proof include:
• certificate of Indian Status, a status card or a valid band a certified copy of a Nunavut Trust Certificate card
membership card or Inuit beneficiary card
• letter from your band verifying your status letter of support from Aboriginal Affairs and Northern
• Metis membership card or letter issued by the Metis Nation Development Canada (AANDC) or Nunavut Tunngavik
you are registered with Incorporated
• letter or membership card from the Metis Settlements for a non-status person, a letter of support from a First
General Council Nations, Metis or Inuit organization

Schools may use discretion and accept other documentation.

Personal Information

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) In itia l

Apartment or Box Number

□ Gender

Birthdate
□ Male

Day
□ Female

M o n th Year

I
___ ___ _l____ l_ I
____ ___

Street Address Are you an Alberta resident*? Q Yes □ No

* You are an Alberta resident if one of the following describes
your situation:
CityATown • You maintained permanent residence in Alberta for
a period of 12 months immediately prior to attending
a post-secondary school, or
Prov/State Country Postal/Zip Code
• Your parents or guardians have maintained permanent
_1_I— I—I—I— L J— I— I— I— L residence in Canada for 12 consecutive months and
Mobile Number (format: 999-999-9999) to receive text messages reside in Alberta, or
• Your spouse!partner is an Alberta resident, or
JL • You have been declared, or fall within a class of persons
Telephone Number (format: 999-999-9999) declared, to be a resident in Alberta by the Minister.
_L Alberta Student Number (obtained from Alberta
Email Address Transcript of High School Achievement)

Citizenship Status: (check one)

□ Canadian □ Permanent Resident □ Protected Person

IN D IG E N O U S C A R E E R S A W A R D - S c h o o l a d m in is te r e d v e rs io n - L a s t re v is e d D e c e m b e r 2 0 1 5 Page 588
 Page 2
Full-time Studies Information

Name of School

Program

Program Specialization/Major

Program Outcome What year of this program will you be in? (check one)
□ Certificate □ 1st year or less □ 2nd year □ 3rd year Q 4th or 5th year
□ Diploma Length of your program of studies (check one)
□ Degree □ 1 year or less □ 2 years □ 3 years □ 4 or 5 years

Enter your program session start and end dates for the current school year.

Start End
Day M o n th Year Day M o n th Year

I
___ ___ J ______ L I
___ ___ I
___ ___ J ______ L I
___ ___

Additional Questions

(School should insert information about the additional eligibility criteria that it will require and add any questions or requirements
for the Applicant to fill in as necessary.)

Declaration of Applicant

have read and understand the instructions, and declare that:

» all information provided is true and complete and I understand it is subject to verification.
» I will immediately notify______________ (School Name)______________ jf there are any changes to the information I have
provided in this application.

I authorize my post-secondary institution to disclose information collected on this application form, my program of study and any
award details (if I am selected) to Student Aid Alberta, and I authorize Student Aid Alberta to collect this information from the post­
secondary institution for the purposes of administering the Indigenous Careers Award under the Student Financial Assistance Act,
including confirming my eligibility and suitability for this award, for program evaluation and for research and statistical analysis.

Signature of Applicant (in ink) Today’s Date (in ink)

Day M o n th Year

X
_ u ! I I i i i

Page 589
 Student Aid Alberta Indigenous Graduate Award
Award Value - up to $15,000

The Indigenous Graduate Award is designed to encourage a larger proportion of Indigenous Albertans (First Nations, Metis, and Inuit) to pursue
graduate studies in Alberta.

Indigenous Ancestry and Residency Requirements Value of Award

You must be Status Indian/First Nations, Non-Status Indian/
First Nations, Metis, or Inuit and be able to provide proof of
Indigenous ancestry.
You must be a Canadian Citizen or Permanent Resident
of Canada and an Alberta resident.
The value of this award can range between a minimum of
$7,500 to a maximum of $15,000. Schools determine the
specific amount to award each eligible applicant.
Other Eligibility Criteria (if required)

Eligible School Requirement (Schools may insert any additional eligibility requirements.)
You must be attending a participating public post-secondary
school in Alberta.

Course Load and Study Requirements

You must be enrolled in the 2015-16 winter semester
in order to be considered for these awards.
You must be enrolled in at least 60% of a full course load.
If you are a student with a documented permanent disability,
you can be eligible if you are enrolled in at least 40% of a full
course load.
Your school determines what constitutes a full-time course
load in each program.
Co-op students, students in brokered programs, and students
who are participating in an official exchange may be eligible.
You must be in satisfactory academic standing as determined
by your school - satisfactory academic standing may vary in
how it is determined by school or program.
You are not eligible to receive the award if you:
- withdraw from studies, or
- drop from full-time to part-time studies before the
award is paid

Credential and Eligible Programs of Study

You must be enrolled in a master’s degree or doctoral
degree program that is approved by the Minister of
Advanced Education.

How to Apply
You must apply to the school you are attending. Check with
your school for application deadlines.
If you are a co-op student, a student in a brokered program,
or participating in an official exchange, you must apply through
the school that will issue your post-secondary credential.

Page 590
 insert School Name or Logo Indigenous Graduate Award
Student Aid Alberta

FOIP Collection Notice

(Schools must provide FOIP collection notices.;

Indigenous Ancestry

Please indicate your Indigenous Ancestry:

□ Status Indian/First Nations □ Non-Status Indian/First Nations □ Metis □ Inuit

Documentation Requirements: You must provide proof of your Indigenous ancestry to your school to determine your eligibility.
Acceptable documents of proof include:
• certificate of Indian Status, a status card or a valid band a certified copy of a Nunavut Trust Certificate card
membership card or Inuit beneficiary card
• letter from your band verifying your status letter of support from Aboriginal Affairs and Northern
• Metis membership card or letter issued by the Metis Nation Development Canada (AANDC) or Nunavut Tunngavik
you are registered with Incorporated
• letter or membership card from the Metis Settlements for a non-status person, a letter of support from a First
General Council Nations, Metis or Inuit organization

Schools may use discretion and accept other documentation.

Personal Information

Last Name (current full legal name) Social Insurance Number

M id d le
First Name (current full legal name) Initial

Apartment or Box Number

□ Gender

Birthdate
□ Male

Day
□ Female

M o n th Year

I
___ ___ _l____ l_ I
____ ___

Street Address Are you an Alberta resident*? Q Yes □ No

* You are an Alberta resident if one of the following describes
your situation:
CityATown • You maintained permanent residence in Alberta for
a period of 12 months immediately prior to attending
a post-secondary school, or
Prov/State Country Postal/Zip Code
• Your parents or guardians have maintained permanent
_1_I— I—I—I— L J—I—I—I—L residence in Canada for 12 consecutive months and
Mobile Number (format: 999-999-9999) to receive text messages reside in Alberta, or
• Your spouse!partner is an Alberta resident, or
JL • You have been declared, or fall within a class of persons
Telephone Number (format: 999-999-9999) declared, to be a resident in Alberta by the Minister.
_L Alberta Student Number (obtained from Alberta
Email Address Transcript of High School Achievement)

Citizenship Status: (check one)

□ Canadian □ Permanent Resident □ Protected Person

IN D IG E N O U S G R A D U A T E A W A R D - L a st revised D e ce m b e r 2 0 1 5 Page 591

 Page 2
Full-time Studies Information

Name of School

Program

Program Specialization/Major

Program Outcome What year of this program will you be in? (check one)
□ Degree - Masters Q 1st year or less □ 2nd year □ 3rd year Q 4th or 5th year

Q Degree - Doctoral Length of your program of studies (check one)

□ 1 year or less □ 2 years □ 3 years □ 4 or 5 years

Enter your program session start and end dates for the current school year.

Start End
Day M o n th Year Day M o n th Year

I
___ ___ J ______ L I
___ ___ I
___ ___ J ______ L I
___ ___

Additional Questions

(School should insert information about the additional eligibility criteria that it will require and add any questions or requirements
for the Applicant to fill in as necessary.)

Declaration of Applicant

I have read and understand the instructions, and declare that:

• all information provided is true and complete and I understand it is subject to verification.
• I will immediately notify______________ (School Name)______________ if there are any changes to the information I have
provided in this application.

I authorize my post-secondary institution to disclose information collected on this application form, my program of study and any
award details (if I am selected) to Student Aid Alberta, and I authorize Student Aid Alberta to collect this information from the post­
secondary institution for the purposes of administering the Indigenous Graduate Award under the Student Financial Assistance Act,
including confirming my eligibility and suitability for this award, for program evaluation and for research and statistical analysis.

Signature of Applicant (in ink) Today’s Date (in ink)

Day M o n th Year

X
_ u ! I I i i i

Page 592
SCiP
Serving Communities
Suite #609,10080 Jasper Avenue, Edmonton, AB T5J 1V9
Toll Free in Alberta: 1-877-915-6336x225
Phone: 780-482-3300x225
Fax: 780-482-3310

Internship Program — — <

Bursary Payment Request

Note: You must include your Alberta Student Number on this form . This is a number provided by the
Government o f Alberta, not the student ID number provided by your educational institution. You may
fin d your Alberta Student Number here: https://extranetapp.learning.gov.ab.ca/learnerRegistry/forms/

This fo rm m ust be com pleted by th e stu d e n t in ink and m ailed or dropped o ff to:

V o lu n te e r Alberta
c /o SCiP
Suite #609
10080 Jasper Avenue
Edm onton, ABT5J 1V9

Scanned/faxed docum ents will not be accepted.

Volunteer Alberta requires the following in order for a student to receive their bursary:

• Letter o f A greem ent (sent at th e beginning o f th e internship)

• End o f Internship Declaration (original document, provided by th e organization)
• Bursary Paym ent Request (original document, fille d o u t by th e student)
• P roof o f E nrolm ent (original document, provided to th e stu d e n t by education
in s titu tio n )

Page 593
 Serving Communities Internship Program
Bursary Payment Request
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your
eligibility for an award under the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship
Programs. If you have any questions about the collection of this information, please contact Alberta Scholarship
Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone (780) 427-8640.

Personal Information
Social Insurance Number

Surname

Given Name

Street Address

City/Town _____________________ Postal Code_______________

Birth Date (Day/ Month/ Year) ____________________

Gender (M or F) _____ Phone No. _________________________

Alberta Student Number ______________________________

Email Address ______________________________

Education Information
Post-secondary Institution _________________________________________

Start & Finish Dates _________________________________________

YOU MUST COMPLETE AND SIGN THE OTHER SIDE OF THIS FORM
Office Use Only

123
GRANT
04 $1,000
TO TAL AW D IN S T IT
11 8 8 8
PGM
13
MO YR MO YR
18
c
ORG
) 2

ADD

Disbursement E
MO YR A S P A U T H O R IZ A T IO N AW A RD KEY APP KEY

Page 594
 Serving Communities Internship Program
Bursary Recipient

Internship Information
NonProfit/Voluntary
Organization
Internship Start
& Finish Dates)

Declaration of Applicant

I declare that:
a. all information provided is true and complete and I understand it is subject to audit;
b. I was a student registered either full or part-time at one of the qualifying institutions during the
academic year (August 1 to July 31) that I began my internship.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic enrolment status may be released
and exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for this award;
b. my personal information may be released and exchanged by and between Alberta Enterprise and
Advanced Education and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Enterprise and Advanced Education, and for the use in research
and statistical analysis in program evaluation; and,
c. if I receive an award my name, city/town, and the name of the associated volunteer organization may
be released publicly to promote the program, however, this is not a criterion for eligibility, and if I do
not want to be identified, I will contact Alberta Scholarship Programs.

Signature (in ink) Today’s date

If you have any questions concerning this form please contact Alberta Scholarship Programs at (780) 427 8640 or
by e-mail to scholarships@gov.ab.ca

Page 595
SCiP
Serving Communities
Suite #609,10080 Jasper Avenue, Edmonton, AB T5J 1V9
Toll Free in Alberta: 1-877-915-6336 x225
Phone: 780-482-3300 x225
Fax: 780-482-3310

Internship Program

End of Internship Declaration

This d ocu m e n t is to be com pleted by th e organization. It m ust be signed in ink and m ailed or
dropped o ff to:

V olu n te e r A lberta
c/o SCiP
Suite #609
10080 Jasper Avenue
Edm onton, ABT5J 1V9

Scanned/faxed docum ents and electronic signatures will not be accepted.

Volunteer Alberta requires the following in order for a student to receive their bursary:

• Letter o f A greem ent (sent at the beginning o f th e internship)

• End o f Internship Declaration (original document, provided by the organization)
• Bursary Paym ent Request (original document, fille d o u t by th e student)
• P roof o f E nrolm ent (original document, provided to th e stu d e n t by educational
in s titu tio n )

Page 596
 SCiP
Serving Communities
End of Internship
Declaration
Internship Program

This le tte r is to c e rtify th a t [In te rn ] has com pleted a SCiP-approved in ternsh ip at [Name
o f O rganization].

As the [Internship T itle ], [In te rn ] sa tisfactorily com pleted the fo llo w in g deliverables:

• Deliverable
• Deliverable
• Deliverable

betw een [start date] and [end date], as per th e Letter o f A greem ent signed by both the
organization and in tern at the start o f th e internship.

Please pay th e $1000 bursary to [In te rn ],

[Name o f Inte rn 's Supervisor] Date

[Position]
 Serving Communities Internship Program
Bursary Payment Request
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of
Information and Protection of Privacy Act (FOIP Act), as being directly related to and necessary to determine your
eligibility for an award under the Alberta Heritage Scholarship Act and to administer the Alberta Scholarship
Programs. If you have any questions about the collection of this information, please contact Alberta Scholarship
Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone (780) 427-8640.

Personal Information
Social Insurance Number ______________________________________

Surname ______________________________________

Given Name ______________________________________

Street Address ______________________________________

(your cheque will be mailed to this address) _______________________________________________________________

City/Town _____________________ Postal C ode____________

Birth Date (Day/ Month/ Year) ____________________

Gender (M or F) _____ Phone No. _________________________

Alberta Student Number ______________________________
You may use the Learner Registry at www.education.gov.ab.ca to find your 9 digit Alberta Student Number or to have one assigned

Email Address ______________________________

Education Information
Post-secondary Institution ______________________________________

Start & Finish Dates ______________________________________

YOU MUST COMPLETE AND SIGN THE OTHER SIDE OF THIS FORM
Office Use Only

123 04 $1,000 11 8 8 8 13 18 © 2
GRANT TO TAL AW D IN S T IT PGM MO YR MO YR ORG ADD

Disbursement E

MO YR A S P A U T H O R IZ A T IO N AW A R D KEY A P P KEY

Page 598
M arch 2014
 Serving Communities Internship Program
Bursary Recipient

Internship Information
NonProfit/Voluntary
Organization
Internship Start
& Finish Dates)

Declaration of Applicant

I declare that:
a. all information provided is true and complete and I understand it is subject to audit;
b. I was a student registered either full or part-time at one of the qualifying institutions during the
academic year (August 1 through July 31) that I began my internship.

I understand and agree that:

a. my personal information pertaining to my post-secondary academic enrolment status may be released
and exchanged by and between Alberta Scholarship Programs and the educational institution for the
purpose of determining my eligibility for this award;
b. my personal information may be released and exchanged by and between Alberta Innovation and
Advanced Education and any provincial government departments, boards or institutions to verify the
information 1have provided to Alberta Innovation and Advanced Education, and for the use in research
and statistical analysis in program promotion and/or evaluation; and,
c. if I receive an award my name, city/town, and the name of the associated volunteer organization may
be released publicly to promote the program, however, this is not a criterion for eligibility, and if I do
not want to be identified, I will contact Alberta Scholarship Programs.

Signature (in ink) Today’s date

If you have any questions concerning this form please contact Alberta Scholarship Programs at (780) 427-8640 or
by e-mail to scholarshit>s@,gov.ab.ca

Page 599
M arch 2014
Sir James Lougheed

Award of Distinction
 SIR JAMES LOUGHEED AWARD OF DISTINCTION
The Sir James Lougheed Award of Distinction honours the Calgary lawyer, parliamentarian, senator and cabinet minister who
served in several federal parliaments in the late 1800s and early 1900s.

This award recognizes academic excellence and provides Alberta students in graduate programs with the opportunity for study outside
of Alberta at institutions anywhere in the world. Each year up to fifteen students may be eligible for awards.

Award Value
Master Level $15,000 Doctoral Level $20,000

Eligibility Criteria
Applicants must:
• be either a Canadian citizen or a Permanent Resident,
• be an Alberta resident, and
• enrolled or planning to enroll as a full-time student in a graduate program at an institution outside Alberta.

Recipients are eligible to re-apply, however, there is a lifetime limit of two scholarships.
Recipients will be advised of their eligibility to hold other awards or to accept partial teaching assignments, or other remunerative
assignments.
In order to qualify for a doctoral level scholarship, a student must have completed at least one full year of graduate study or a
masters degree.

Application Procedures
An application form can be obtained from our website, however, you cannot submit your application electronically. Complete the
application form and mail the original and attachments, unstapled.

Academic transcripts and appraisals can be sent directly to Alberta Scholarship Programs. Applicants must ensure their application
is complete. To verify the completeness of your application, send an email to our office: scholarships@gov.ab.ca with your full
name and social insurance number.

FAXED APPLICATIONS ARK NOT ACCEPTED

Mail to: Courier to:
Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940-106 Street
EDMONTON AB T5J 4R4 EDMONTON AB T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab
Website: alis.alberta.ca/scholarships

Selection Criteria
Applications are evaluated by a committee appointed by the Presidents of the universities in Alberta. Applications are judged on
previous academic accomplishments, program of study, appraiser evaluations, answers to the essay question, and general
impressions from the application form.

A pplication Deadline: February 1

Deadline fo r subm itting academic transcripts and appraisals: February 15
 APPLICATION FOR
SIR JAMES LOUGHEED AWARD OF DISTINCTION

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
You may use the Learner Registry at www.cducation.gov.ab.ca to find your Alberta Student Number or to have one assigned.

Province Postal Code Area Code Telephone Number

Date of Birth Gender Email Address

M F
__ l______ I______I___ I___I___
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Have you lived in Alberta all your life?_____ Is Alberta the last place you spent 12 consecutive months
Y N If no, since outside of school? Y N
___ I___ ___I___ I___ I___
month year
Do either of your parents live in Alberta?

POST-SECONDARY EDUCATION
Highest degree completed:_____________________

Current institution: Name of program:

OR Last institution attended: Name of program:

Revised: May 2013

Page 602
 Education Information
(Note: This award is for graduate study outside of Alberta only)

Name of institujion you will attend this fall?

Level of study: (check one)

^M asters | | Ph.D.

What is your Thesis or Project title?_______

Please submit a resume and include the following: all Universities, Colleges or Technical Institutes attended to date, including
current institution; list scholarships, awards and other forms of achievement received; indicate any publications, if any, such as
the name of the journal they were published in, also include, if applicable, any presentations/performances/exhibitions (dates,
locations, etc.).

Essay Question

Title of your proposed program of study

In two pages or less, please provide a detailed description of your proposed program of study, why you are
pursuing your research (if applicable) or creative activity, and what you plan to accomplish during and after your
studies.
Please attach these pages to your application. Pages must be single-spaced, and enough space between the lines
for legibility, approximately six lines per vertical inch. Font size should not be less than 10 and condensed type
is not acceptable.

Application Deadline: February 1

Deadline for submitting academic transcripts and appraisals: February 15
 References

Name the two individuals who will be submitting a letter of appraisal. Note to Appraisers: since there arc numerous
candidates competing for a limited number of awards, it is important that you provide as much detailed information on the
applicant’s program of study, accomplishments and area of research.

Name Position Held

Institution

Name Position Held

Institution

Below, list the institutions you are requesting transcripts from (include your surname if it is different on the transcript). If
you applied last year and wish to use the same transcript, please indicate the specific transcript(s).

Page 604
 Declaration of Applicant
I have read and understand the instruction, and declare that
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I
withdraw from full-time studies before completing one semester of studies.
I understand and agree that
a. my personal information pertaining to my post-secondary academic record may be released
and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may
be released and exchanged by and between Alberta Scholarship Programs and the
educational institution for the purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Scholarship Programs and for the use in research and
statistical analysis in program evaluation.
I understand and agree that
if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want to
be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Complete package must be postmarked no later than February 1.

Official transcripts and appraisals must be postmarked no later than February 15.
Notification of results may be expected in April.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund
is designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting
Albertans to achieve their fullest potential.

Alberta Scholarship Programs administers another graduate scholarship, the Arts Graduate Award for Master level study in the field of
the Arts. Information on this scholarship is available on our website.

For information on other awards administered by Alberta Scholarship Programs

visit our website; alis.alberta.ca/scholarships
 Senior M anagem ent Team Decision Request
StudentAidAlberta SMT-DR-NY2015-###

SMT Decision Request

Name of Decision Request

Presented By

Issue

Background
Rationale &
Recommendation

Approval Approval may be required by one or both groups:

Required
□ SA SENIOR MANAGEMENT TEAM □ LEGAL
By

Submitted by: Name Working Unit Date

Working
Committee

Approved by: Name Branch Approved

Steering
Committee
(Directors)

Legal

Name of Decision Request SMT Decision Request - MTH/DD/YYYY Page 1 o f 1

SMT-DR-NY2015-### ______Page 606
 PPRS - Loans
Date:
Special Consideration
Student Aid Alberta
Assessment

N A M E : _____________________________________________________ S IN :

A c a d e m ic Y e a r E n d : _________________________________________ Illn e s s D a te :

Loan Type Amount Service Provider RAP Months - End Date

Direct Loan

Crown Debt Collection

Risk Share Loan

Guaranteed Loan

Canada Loan

C S L e tte r O p tio n s : ___________________________________________D a te :

Documents Provided Date Received

Letter/Request Received

Medical Document Received

Income & Expense Received

Follow up CS Letter Options: ______________________________________________ Date:

Documents Forward to :________________________________________________________

Comments:__________________________________________________________________

□ APPROVED: GL RS DL Signature: Date:

□ Remove Permanently □ Review in Months

□ DENIED: GL RS DL Signature: Date:

Reason for Denial:

Student Notified: □ Yes O No CS Letter Options: Date:

SP requested to RTG and/or submit a Claim: GL RS DL Initials:__________________________

Special Consideration Assessment Sept 2014

Page 607
Spouse/Partner Information 2015/2016
Applicants who are Married or Common Law*
* You are considered to have a common law partner if:
• you and an individual have lived together in a conjugal relationship
continuously for the past one year, or
Schedule 2
1 5 /1 6 S2
you have declared an individual to have a status equivalent to that of
your common law partner under any law of Alberta or of Canada, or
you and an individual are living together in a conjugal relationship where
there are one or more children of the relationship by birth or adoption.

Applicant’s Last Name Initials Social Insurance Number

I I I I I I I I I I I I I I I
Spouse/Partner Information and Declaration: (to be completed by Applicant’s spouse/partner)

Notice to Spouse/Partner: If you do not wish to include your personal information with the Applicant’s Application package,
you may submit a completed Schedule 2 separate from the Application to: Student Aid Alberta, PO Box 28000 Stn Main,
Edmonton AB T5J 4R4.

Spouse/Partner Information
Spouse/Partner Social Insurance Number

Spouse/Partner Last Name Spouse/Partner First Name

Spouse/Partner Birthdate Date spouse/partner completed/last attended regular High School

(excludes upgrading)
Day Month Year
Month Year
__ i__ I , , 1 __ i__
J _____ L __ l__

Have you lived in Alberta all your life? □ Yes LI No

If no, is Alberta the last province you have lived in for 12 consecutive months without being a full-time student? _| Yes No

Total income (Line 150 of 2014 Income Tax Return) (mandatory) (see Quick Tips p.13 #6) $

Spouse/Partner Income Status

I Employed
_| Unemployed with income (WCB, El, etc.)
J Assured Income for the Severely Handicapped (AISH)
J Aboriginal Affairs and Northern Development Canada/Band Funds
I Unemployed due to medical condition (Keep your doctor’s letter as this will be audited)
_| Unemployed no income

Spouse/Partner Gross Monthly Income $

Spouse/Partner Net Monthly Income (this amount must equal

the Spousal/Partner Net Income entered on Page 3) } (see Quick Tips
p.15 #15)

Month Year
Date income starts
I ___ I____ l ____l____

If your income will end during the Applicant’s study period, Month Year
indicate date
■ ■ l ___ 1____ 1____ 1____
Spouse/Partner School Status
Will you be a full-time student at any time during the Applicant’s study period? □ Yes □ No

If yes, date you Day Month Year Date you Day Month Year
start school ■ 1__ i i__ L__ 1____1____1___ end school ■ 1 ■ l 1__ 1___ 1____1___
If both you and the Applicant are attending full-time studies, you should both complete a separate application form for student aid.

Signatures required on next page Page 608

Spouse/Partner Information 2015/2016 Schedule 2
Applicants who are Married or Common Law

Innovation and Advanced Education is collecting this personal information under the authority of sections 33(a) and (c) of the Freedom
of Information and Protection of Privacy Act (Alberta) (“FOIP”) to determine and verify the Applicant’s eligibility for financial assistance,
to administer (including research, statistical analysis, and evaluations) and to enforce student financial assistance programs in
accordance with the Student Financial Assistance Act (Alberta), the Canada Student Loans Act and the Canada Student Financial
Assistance Act, each as may be amended from time to time. The use and disclosure of your personal information is managed in
accordance with FOIP.
The personal information may be disclosed to:
• federal, provincial or territorial government departments or agencies to verify any information the Applicant provided, determine
the eligibility of the Applicant for financial assistance and to administer student financial assistance programs.
• the federal government for use in research, statistical analysis and evaluations related to student financial assistance programs.
• Alberta Fluman Services to operate and administer provincial and federal student financial assistance programs, including your
eligibility, and the eligibility of the Applicant, for financial assistance.
• any municipal government department or agency, landlord, lending institution, credit bureau or employer to verify any information
the Applicant provided, to determine the eligibility of the Applicant for financial assistance and to administer student financial
assistance programs.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free
at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, Privacy Officer, PO Box
28000 Stn Main, Edmonton AB T5J 4R4.

Spousal/Partner Declaration:
• I declare that the information given on this Schedule is true and complete.

For the purpose of verifying the data provided in this Application for student financial assistance, I hereby consent to the release,
by Canada Revenue Agency to an official of Innovation and Advanced Education, of information from my income tax returns and, if
applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant
to and used solely for the purpose of determining and verifying the Applicant’s eligibility, entitlement for and the general administration
and enforcement of the student financial assistance programs under the Canada Student Loans Act, the Canada Student Financial
Assistance Act, the Students Finance Act (Alberta), the Student Loan Act (Alberta) and the Student Financial Assistance Act (Alberta).
This authorization is valid for the taxation year prior to the year of signature of this consent, the year of signature of this consent and
any other subsequent taxation year for which assistance is requested by the Applicant.

Signature of Spouse/Partner Today’s Date

Day Mont h Year
X
_ i _ l i l l I I !

Upload or Mail Your Form

Send documents electronically* Mailing Address

1. Visit studentaid.alberta.ca STUDENT AID ALBERTA
2. Sign in via SFS Login PO BOX 28000 STN MAIN
3. Submit securely using e-Document Upload EDMONTON AB T5J 4R4
‘For assistance: e-Doc Upload FAQ

Page 609
yQ^iae^bcyJi
STATUTORY DECLARATION - Cheque has been cashed.
This form should be completed in handwriting.

I ,.
(Full Name of Payee) Please print
of
(Street Address, City/town, Province)
do solemnly declare:
I. That I am the named payee on cheque numbered _________ dated________ for the amount of $______
issued by HER Majesty the Queen in right of the Government of Alberta, Minister of Finance, hereinafter referred
to as “the original cheque”.
II. That I have not benefited either directly or indirectly by the proceeds of the original cheque.
III. That I have examined the original cheque or a photocopy of the original cheque, showing an endorsement of my
name.
IV. That the following are two specimens of my signature: __________________________________
(Signature)

(Signature)
V. That the answers to the questions below are given by me and are true to the best of my knowledge, information
and belief.
(1) Did you receive the original cheque or did you ever see it? ________________________________________

(2) If you did receive the original cheque, or if you ever saw it, please explain the facts of circumstances that led
to its loss._________________________________________________________________________________

(3) Did you endorse the original cheque?_________________________________________________________

(4) Was the endorsement of your name on the original cheque made with your consent or by agreement or
understanding with anyone?_________________________________________________________________
(5) If you did not receive the original cheque, do you know who received the original cheque or who endorsed
your name on it or who received any benefit in money or credit or anything of value from the cashing of the
original cheque? (Please provide details.)

(6) Where do you usually cash your cheques?______________________________________________________

The personal information being collected on this form is collected for the purposes of validating a claim for a lost, destroyed or stolen payment and
re-issuing funds. The information may also be used for law enforcement purposes. The collection is authorized under sections 33(b) and (c) of the
Freedom of Information and Protection of Privacy Act and will be managed in accordance with the provisions under the Act. If you have questions
about the collection of this information, please call Student Aid Alberta, Privacy Officer at 780-427-9639. You can also mail your questions to
Student Aid Alberta, Executive Services, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Page 1 of 2
Page 610
 (7) Are you known in the financial institution or place where the original cheque was cashed?

(8) What was your mailing address on the date the original cheque was due to arrive?

(9) What are the names and addresses, and relationship to you, of any persons who resided with you at the
time, at the address described in number (8)?________________________________________________

(10) Where and with whom did the Postal employee leave your mail? Also state your forwarding address, if one
was used._________________________________________________________________________________

(11) Do you have any reason to believe that the cheque was endorsed or that the proceeds of the original cheque
were received by any member of your family, by any associate or by any other person whose name is listed
in the answer to number (9)?_________________________________________________________________

(12) Do you have knowledge of any other facts or circumstances that led to the loss, theft, or cashing of the
original cheque?________________________________________________________________________
If so, please provide details:______________________________________________________________

(13) I have asked Alberta Innovation and Advanced Education (Student Aid) to issue a new cheque to replace the
original cheque.

AND I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true and knowing that it is of the same
force and effect as if made under oath.

DECLARED before me at th e ____________ o f_______________

in the Province o f________________________________________
th is_________ day o f________________ , 20_____ .

(Commissioner for Oaths in and for the Province of Alberta) (Signature of Payee)

PRINT NAME OR STAMP HERE________________

Appointment Expires_______________________ , 20

The personal information being collected on this form is collected for the purposes of validating a claim for a lost, destroyed or stolen payment and
re-issuing funds. The information may also be used for law enforcement purposes. The collection is authorized under sections 33(b) and (c) of the
Freedom of Information and Protection of Privacy Act and will be managed in accordance with the provisions under the Act. If you have questions
about the collection of this information, please call Student Aid Alberta, Privacy Officer at 780-427-9639. You can also mail your questions to
Student Aid Alberta, Executive Services, PO Box 28000 Stn Main, Edmonton AB T5J 4R4.

Page 2 of 2
Page 611
Government of Alberta ■
Student Aid Alberta Student File Review
Background Information
REQUESTED BY______________________________________
DATE_______________________________________________
STUDENT NAME_____________________________________
ASN/SIN
INSTITUTION________________________________________
SESSION DATES______________________________________
PROGRAM/ YEAR OF STUDIES
REASON FOR REVIEW

O PTIO N S/RECO M M EN DATIO N

RESULTS:
I d e c lin e d " [ approved ^ M O D IF IE D AS FOLLOWS
CSLP
MODIFIED ACTION REQUIRED:

POLICY REVIEW REQUIRED:

REVIEWED BY:

COMMENTS:

Page 612
 Student Aid Alberta Students Finance System & COR Access Form

Instructions for Designated Representative (Signing Authority):

• Please ensure your school has already signed a Student Aid Alberta: Access to Learner Information
Agreement (ALIA) before proceeding to complete this form.

o If you have questions regarding the ALIA agreement, email us at:

o EAE.SAACORAccess@gov.ab.ca

. Access to the Students Finance System (SFS) is only available through the Extranet, a secure,
authenticated e-information service providing for the exchange of confidential data between
Student Aid Alberta and its external stakeholders. Designated Staff requiring access to the Students
Finance System must complete the following steps before the Designated Representative with signing
authority can submit this form:

1. Set up an Extranet account

2. Create a unique profile and link it their school and/or each campus location

If Designated Staff at your school have not completed these steps, please refer them to:

o Resources for Schools/SFS-COR Access

• Use this form to either grant/remove Designated Staff access to Alberta's Students Finance System.
System access gives Designated Staff the ability to inquire/or perform Confirmation of Registration (COR)
functions for students who have received funding from Student Aid Alberta.

• When Designated Staff are employed across multiple locations/campuses, they must create a separate
Extranet profile and submit a new Students Finance System Access Form for each campus location where
financial assistance is provided to students.

• Student Aid Alberta will use this information to maintain a comprehensive list of authorized users on the
Extranet who are routinely accessing secure information on the Student Finance System.

• The educational institution's Designated Representative must read and sign the declaration on page 2
of this form. The Designated Representative must also provide the name and contact information for all
Designated Staff in order to have them either added or removed from the SFS system.

Sign and return completed form to Student Aid Alberta at:

Email: EAE.SAACORAccess@gov.ab.ca Fax:780 422-4517

Instructions for Designated Staff:

• Once Student Aid Alberta receives and approves access for each designated staff member listed on this
form, the designated staff member(s) will receive an email informing them of having been given access to
SFS inquiry and COR (Confirmation of Registration) functions.

Dec 2015 Page 1 o f 2

Page 613
 Students Finance System & COR Access Form fo r Designated Representative / page 2

Pursuant to the Alberta Students Finance System (SFS) Access to Learner Information Agreement
(the "Agreement") between Her Majesty the Queen in Right of Alberta as represented by the Minister of
Advanced Education ("Alberta") and the Educational Institution, the Educational Institution is required to provide
Alberta with the names and email addresses of employees, officers and agents of the Educational Institution that
require access to the SFS for the purposes of providing assistance to Learners regarding Financial Assistance
and/or to provide electronic confirmation of registration services.

To be completed by the Educational Institution's representative for the purposes of authorizing Designated Staff
(i.e. the position as stated in clause 10.S of the Agreement) who require access to Students Finance System.

Name of Educational Institution:____________________________________________________________________

Location / Campus:_______________________________________________________________________________
Institution Number from PAPRS (if known):

AUTHORIZATION:

I authorize the following individuals as Designated Staff pursuant to the Agreement. I understand that:

• I am responsible for contacting the Student Aid Alberta office to identify newly Designated Staff requiring
access to SFS for the purposes of their current position at the Educational Institution.
• If a Designated Staff leaves or is removed from his/her position or it is no longer necessary for the
Designated Staff to access SFS for the purpose of their employment responsibilities, I am responsible for
immediately informing Student Aid Alberta to revoke the Designated Staff's Login ID.
• For security reasons, Login ID and Password may be revoked by Alberta at any time without notice.
• Each of the Designated Staff has undergone Confidentiality Training, as defined in the Agreement and has
been made aware that:
o Login IDs and Passwords must be kept confidential.
o Any use of information obtained from the SFS will be subject to the provisions of the Freedom o f
Information and Protection o f Privacy Act.
o Access to information obtained from SFS is on a need-to-know basis.

N am e__________________________ Position ________________________ Email Address

Signature Date Phone Number

Name of Designated Staff Email Address of Designated Staff Provide Remove

Access Access

Dec 2015 Page 2 o f 2

Page 614
 Student Aid Alberta Students Finance System Access Form

To be completed by the Educational Institution’s representative for the purposes of authorizing

Designated Staff who require access to the Students Finance System.

P u rs u a n t to th e A lb e rta S tu d e n ts F in a n c e S y s te m (S F S ) A c c e s s to L e a rn e r In fo rm a tio n A g re e m e n t (th e

“A g r e e m e n t”) b e tw e e n H e r M a je s ty th e Q u e e n in R ig h t o f A lb e rta a s re p re s e n te d b y th e M in is te r o f
In n o v a tio n a n d A d v a n c e d E d u c a tio n (“A lb e r ta ”) a n d th e E d u c a tio n a l In s titu tio n , th e E d u c a tio n a l
In s titu tio n is re q u ire d to p ro v id e A lb e rta w ith th e n a m e s a n d e m a il a d d re s s e s o f e m p lo y e e s , o ffic e rs a n d
a g e n ts o f th e E d u c a tio n a l In s titu tio n th a t re q u ire a c c e s s to th e S F S fo r th e p u rp o s e s o f p ro v id in g
a s s is ta n c e to L e a rn e rs re g a rd in g F in a n c ia l A s s is ta n c e a n d /o r to p ro v id e e le c tro n ic c o n firm a tio n o f
re g is tra tio n s e rv ic e s .

T h e E x tra n e t is a s e c u re , a u th e n tic a te d e le c tro n ic in fo rm a tio n s e rv ic e to p ro v id e fo r th e e x c h a n g e o f

c o n fid e n tia l d a ta w ith e x te rn a l s ta k e h o ld e rs .

A lb e rta w ill a s s ig n e a c h D e s ig n a te d S ta ff a u n iq u e p ro file to a llo w A lb e rta to m a in ta in a c o m p re h e n s iv e

lis t o f a u th o riz e d u s e rs th a t w ill u s e th e E x tra n e t to a c c e s s th e S tu d e n t F in a n c e S y s te m .

INSTRUCTIONS TO DESIGNATED STAFF

1) B e fo re c o m p le tin g th is S tu d e n ts F in a n c e S y s te m A c c e s s F o rm , a ll D e s ig n a te d S ta ff m u s t firs t
h a v e c re a te d a n a c c o u n t a t https://phoenix.edc.qov.ab.ca/
G o to ‘S ig n In ’, th e n ‘S ig n U p fo r a n e w A lb e rta E d u c a tio n A c c o u n t', a n d fo llo w th e p ro m p ts .

2) O n c e y o u h a v e y o u r u s e r n a m e a n d p a s s w o rd , y o u m u s t a ls o c re a te a p ro file to a s s o c ia te y o u r
u s e r n a m e w ith y o u r in s titu tio n . T o c o m p le te y o u r p ro file s e t-u p , y o u w ill p rin t o ff a n d fa x an
A lb e rta E d u c a tio n E x tra n e t U s e r A c c e s s A g re e m e n t to th e H e lp D e s k .
*lf y o u n e e d a s s is ta n c e c re a tin g y o u r a c c o u n t o r p ro file , c a ll th e H e lp D e s k a t 7 8 0 -4 2 7 -5 3 1 8 .

3) A fte r th e H e lp D e s k re c e iv e s y o u r E x tra n e t U s e r A c c e s s A g re e m e n t, y o u w ill re c e iv e a n e m a il

th a t c o n firm s th a t y o u r a c c o u n t a n d p ro file h a v e b e e n s e t up . Y o u m a y n o w s u b m it th is S tu d e n ts
F in a n c e S y s te m A c c e s s F o rm to S tu d e n t A id A lb e rta :

• F a x to 7 8 0 -4 2 2 -4 5 1 7 o r
• S c a n a s a P D F a n d e m a il to : EAE.SAACORAccess@qov.ab.ca

A C T IO N R E Q U IR E D : H a v e y o u r in s titu tio n ’s d e s ig n a te d re p re s e n ta tiv e s ig n a n d re tu rn p a g e 2 o f th e

S tu d e n ts F in a n c e S y s te m A c c e s s F o rm .

U p o n re c e ip t a n d a p p ro v a l o f th e S tu d e n ts F in a n c e S y s te m A c c e s s F o rm , D e s ig n a te d S ta ff w ill re c e iv e
an e m a il in fo rm in g th e m th a t th e y h a v e b e e n g iv e n a c c e s s to S F S In q u iry a n d C O R (C o n firm a tio n o f
R e g is tra tio n ) fu n c tio n s .

For Staff Employed at Multiple Campuses:

Y o u w ill n e e d to c re a te a s e p a ra te p ro file a n d s u b m it a n e w S tu d e n ts F in a n c e S y s te m A c c e s s F o rm fo r
e a c h c a m p u s w h e re y o u p ro v id e fin a n c ia l a s s is ta n c e to s tu d e n ts .

U p d a te d : J u ly 2 0 1 4 Page | 1
Page 615
 Students Finance System Access Form

Sign and return completed form to Student Aid Alberta by Fax - 780-422-4517 or
Sign, scan and email as a PDF to EAE.SAACORAccess@qov.ab.ca

Name of Educational Institution: _________________________________________________________________

Location / Cam pus: ____________________________________________________________________________
Institution Num ber from PAPRS (if known): _______________________________________________________

AUTHORIZATION

To be completed by the Educational Institution’s representative for the purposes of authorizing

Designated Staff (i.e. the position as stated in clause 10.3 of the Agreement). Note: The Educational
Institution must have signed an Access to Learner Information Agreement (ALIA).

I authorize the following individuals as Designated Staff pursuant to the Agreement. I understand that:
• I am responsible for contacting the Student Aid Alberta office to identify newly Designated Staff
requiring access to SFS for the purposes of their current position at the Educational Institution.
• If a Designated Staff leaves or is removed from his/her position or it is no longer necessary for the
Designated Staff to access SFS for the purpose of their employment responsibilities, I am responsible
for immediately informing Student Aid Alberta to revoke the Designated Staff’s Login ID.
• For security reasons, Login ID and Password may be revoked by Alberta at any time without notice.
• Each of the Designated Staff has undergone Confidentiality Training, as defined in the Agreement and
has been made aware that:
o Login IDs and Passwords must be kept confidential.
o Any use of information obtained from the SFS will be subject to the provisions of the Freedom
o f Information and Protection o f Privacy Act.
o Access to information obtained from SFS is on a need-to-know basis.

Name Position Email Address

Signature Date Phone Number

Name of Designated Staff Email Address of Designated Staff Provide Remove

Access Access

□ □
n □
□ □
□ n
cI I□
□ In
U p d a te d : J u ly 2 0 1 4 Page | 2
Page 616
Theodore R. Campbell

Scholarship

Page
 THEODORE R. CAMPBELL SCHOLARSHIP
The Theodore R. Campbell Scholarship recognizes the academic escellence of an aboriginal student enrolled in an education
program at Blue Quills First Nations College. The scholarship was established by the Theodore R. Campbell family through the
Alberta Heritage Scholarship Fund Endowment program.

Award Value - $1,500

Eligibility Criteria
An applicant must:

• be First Nations, Inuit, or Metis and a Canadian Citizen or Permanent Resident,

• be an Alberta resident and to be considred an Alberta resident one of the following conditions must apply:
*one parent must currently be residing in Alberta, or
*Alberta is the last place you have lived for twelve (12) consecutive months before being a full-time student, or
*you are marrried to an Alberta resident before the start of your qualifying year of study,
• have completed the first year of an Education degree (university transfer) at Blue Quills First Nations College,
• have completed a minimum of 24 credits in the first year and obtained passing marks in all courses with at least at 70%
attendance record,
• not be sponsored for their studies,
• demonstrate financial need, and
• be continuing full-time in the second year of the program.

Application Procedure

Application forms are available from the Office of the Registrar at Blue Quills First Nations College. The recipient selected by the
Office of the Registrar.

Return the completed application to:

Office of the Registrar

Blue Quills First Nations College
Box 279
St. Paul, AB TOA 3A0

Information on other awards administered by Alberta Scholarship Programs can be

obtained at:: alis.alberta.ca/scholarships

Application Deadline: June 1

Page 618
 THEODORE R. CAMPBELL SCHOLARSHIP
We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780-427-8640.

Personal Information
Alberta Student Number (go to www.education.gov.ab.ca to fin d your A S N or to have one assigned)Social Insurance Number (required for processing)

Last Name (c u rre n t f u ll leg a l nam e) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll leg a l nam e)

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M
J ____ I____ L
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or | | PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY

month year

POST-SECONDARY STUDIES - 2013-2014 Academic Year

Name of Institution Name of Program

L o c a t i o n ( I f o u tsid e A lb e rta , please p ro v id e co m p le te address.) Length of Program Year of Program

Number of years
□1st □2nd □3rd □4th
I am enrolled in a University transfer program: Academic Year Ends
] Yes ] No ____i____ ____ i____ i____ l____ ____i____ ____ i____ i____ i____
month year month year

Please indicate your aboriginal status: Treaty, Non-Status, C31, Metis or Inuit

Office Use Only

Revised: June 2013

Page 619
 Education Record
Please list the last three schools, colleges or universities that you attended. If you have attended more
than three educational institutions you may include the information on a separate page.

PERIOD OF STUDY INSTITUTION

From (mm/yy) To (mm/yy) Name of Institution Program

Financial Information
Marital Status: Married___ Single ____ Single Parent ___ Number of dependents living with you:

MONTHLY EXPENSES (while in school) MONTHLY INCOME (income while in school)

Rent/Mortgage payment Wages/Salary after deductions

Utilities (power, water, telephone, heating) Spousal/Partner income after deductions

Food/Clothing/Personal Care Contribution from parents

Transportation Child Support/alimony

Child care/Babysitting Government Funding: indicate source:

Additional expenses (i.e. medical)
Other Income (indicate source)
List

Total Monthly Expemses Total Monthly Income

Total Monthly Income X number

Total Monthly Expenses X number of months in school (D)
of months in school (A)

EDUCATION EXPENSES (Include if not covered by sponsorship)

Tuition OTHER RESOURCES

Fees Savings when you start school

Books/Supplies/Instruments Other funding ie. grants, scholarships

(excluding loans and lines of credit)
Total Educational Expenses (B) List:

Total Other Resources (E)

Add together monthly and educational
expenses (A + B) = (C) Add together monthly and Other
Resources (D + E) = (F)
ASSETS Value
Calculated Need:
Registered Retirement Savings Plan Total Expenses (C)____________
Assets (i.e. term deposits, bonds, stocks) Minus Total Resources (F )___________ = Total Need

Total Assets

Page 620
 Declaration of Applicant
I have read and understand the instructions, and declare that
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from
full-time studies before completing one semester of studies.

I understand and agree that

a. my personal information pertaining to my post-secondary academic record and enrolment status may
be released and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the information
I have provided to Alberta Scholarship Programs, and for the use in research and statistical analysis in
program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the
program, however, this is not a criterion for eligibility, and if I do not want to be identified, I will
contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund is
designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting Albertans
to achieve the fullest potential.

Visit alis.alberta.ca/scholarships for information on other awards and scholarships administered by

Alberta Scholarship Programs
 Tiessen Foundation
Broadcast Scholarship

herb Page 622

 Tiessen Foundation Broadcast Scholarship

This award was created to recognize an outstanding Alberta high school student and to encourage and assist students with the
pursuite of post-secondary studies at a broadcast institution in Canada.

Award Value - $750

Eligibility Criteria
Applicant must:
a. be a Canadian citizen or a Permanent Resident,
b. be an Alberta resident - the applicant’s parent(s) must have resided in Alberta during the qualifying grades,
c. have completed Grade 12 at an Alberta high school, and,
d. plan to enroll or be enrolled full-time at any recognized post-secondary institution in Canada that offers degree or diploma
programs in broadcasting such as TV, radio, broadcast engineering

Students should apply in the year they graduate from high school.
Students may only apply once for this award.

Application Procedure
Application forms are available from high school counsellors and Alberta Scholarship Programs.

Applicant must:
* complete an application form,
* include a maximum 750 word essay outlining their interest and pursuit in the field of broadcasting, and
* attach a letter of support from a teacher.

Selection Criteria

A selection committee established by the Tiessen Foundation will select the recipients.

Applicants will be short-listed based on their Grade 12 academic average using the Alexander Rutherford Scholarship criteria.
Copies of the top ten applications will be forwarded to the selection committee who will review the applications and select the
recipient based on the application, essay and letter of support.

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor, 9940 106 Street
Edmonton, Alberta T5J 4R4 Edmonton, Alberta T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Application Deadline: June 1

 Tiessen Foundation Broadcast Scholarship
We are collecting the personal information upon this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy’Act (FOIPAct), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta Heritage
Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this information,
please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information
Alberta Student Number High School Code Social Insurance Number (required for processing)

Last Name (current full legal name) Please use upper and lower case. First Name and One Initial (current full legal name)

Mailing Address (Include Apt. or Box Number) City/Town

Previous Surname
Province Country Postal Code Area Code Telephone Number

Gender (circle one) Date of Birth Email Address

M F dfy | mopth | , yeaf ,

CITIZENSHIP (check one)

CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Attach a a photocopy of permanent resident card or immigration long form. Visa students are not eligible.
ALBERTA RESIDENCY
Do your parents currently live in Alberta? Have you lived in Alberta all your life? If ‘NO’ since
Y N Y N month year
___ I___ ___ I___ I___ I___
I f y ou h av e a n sw e re d “ N O ” to one o f th e A lb e rta R e sid en c y q u e stio n s , p lea se in c lu d e a le tte r e x p la in in g th e tim e s p e n t in A lb e rta
as a n o n fu ll-tim e stu d e n t.

Name of high school you graduated from: __________________________________________________

PROPOSED POST-SECONDARY STUDIES

Institution Code: Post-Secondary. ID. Number Name of Program

Name of Institution Academic Start Date Academic End Date

month | year month | year
____i____ ____ i__ _ i ____ i____ _ l___ I___I___l___ L
Institution City Length of Program Year of Program
y 2nd 3rd

Office Use OnhV

115 8 8 8 1 2

GRANT TOTAL AWD INSTIT PGM MO YR MO YR ORG ADD

J is b u rs e m e n t E

MO YR ASP AUTHORIZATION AWARD KEY APP KEY

Revised: June 2013

Page 624
 Essay

Include with your application, a maximum 750 word essay outlining your
interest and pursuit in the field of broadcasting. It can also include any
work or volunteer experience in the field of broadcasting.

Note: Please include a letter of support from a teacher.

Declaration of Applicant
I HAVE READ AND UNDERSTAND THE INSTRUCTIONS, AND DECLARE THAT:
a. all information provided is true and complete and I understand it is subject to audit,
b. I will be a full-time student at the institution named for the period stated,
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I withdraw from full-time studies
before completing one semester of studies.

I UNDERSTAND AND AGREE THAT:

a. my personal information pertaining to my high school academic record may be released and exchanged by and between
Alberta Education and Alberta Scholarship Programs for the purpose of determining my eligibility for a scholarship,
b. my personal information pertaining to my post-secondary academic enrolment status may be released and exchanged by
and between Alberta Scholarship Programs and the educational institution for the purpose of determining my eligibility
for a scholarship,
c. my personal information may be released and exchanged by and between Alberta Scholarship Programs and any
provincial government departments, boards or institutions to verify the information I have provided to Alberta
Scholarship Programs and for the use in research and statistical analysis in program evaluation.

I UNDERSTAND AND AGREE THAT:

if I receive a scholarship my name, award and city/town may be released publicly to promote the program, however, this is
not a criterion for eligibility, and if I do not want to be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Further information on other awards administered by Alberta Scholarship Programs can be obtained at:
alis.alberta.ca/scholarships
Alberta Ukrainian Centennial

Commemorative
Scholarship
 Alberta Ukrainian Centennial Commemorative Scholarship
The Alberta Ukrainian Centennial Commemorative Scholarship program was established in 1991 by then Premier of Alberta,
Don Getty, on the occasion of the 100th anniversary of the first Ukrainian settlement in Canada. The scholarship acknowledges
the significant contributions of Ukrainian settlers in Alberta and to commemorate the Centennial of Ukrainian settlements in
Canada and Alberta (1891-1991).

Award Value
Up to $25,000

The award covers educational costs (books and tuition), living costs, coverage of Alberta Health and Blue Cross, and one
return airfare.

Eligibility Criteria
One scholarship for a student from Ukraine to study in Alberta and one scholarship for a student from Alberta to study in
Ukraine. Applicants must be enrolled or planning to enroll full-time at the Doctoral or Master level.
While the field of study is open, preference may be given to students in Ukrainian language studies, Canadian Ukrainian
studies, or areas of demonstrable benefit to either Alberta, Ukraine or both.
Applicants must demonstrate proficiency in the use of the English/Ukrainian language acceptable to the institution attended.
Scholarships can be extended for a second year of study upon proof of satisfactory academic progress.

Application Procedures
Submit the original and attachements, and request that original or certified academic transcripts and references be sent directly
to Alberta Scholarship Programs.

Applicants must ensure their application is complete. To verify the completeness of your application, send an email to our
office: scholarships@gov.ab.ca with your full name.

Selection Criteria
Applications are evaluated by a committee appointed by the Presidents of the universities in Alberta. Applications are
judged on previous academic accomplishments, program of study, references, answers to the essay question, and general
impressions from the application form.

FAXED APPLICATIONS ARE NOT ACCEPTED

Mail to: Courier to:

Alberta Scholarship Programs Alberta Scholarship Programs
Box 28000 Station Main 4th Floor-9940 106 Street
Edmonton, AB T5J 4R4 Edmonton, AB T5K2V1

Telephone: 780.427.8640
Email: scholarships@gov.ab.ca
Website: alis.alberta.ca/scholarships

Application Deadline: February 1

Deadline for submitting academic transcripts and references is February 15
 ALBERTA UKRAINIAN CENTENNIAL COMMEMORATIVE SCHOLARSHIP

We are collecting the personal information on this form under the authority of Section 33(c) of the Freedom of Information and Protection
of Privacy Act (FOIP Act), as being directly related to and necessary to determine your eligibility for a scholarship under the Alberta
Heritage Scholarship Act and to administer the Alberta Scholarship Programs. If you have any questions about the collection of this
information, please contact Alberta Scholarship Programs, 4th Floor, 9940 106 Street, Edmonton, Alberta, T5K 2V1 Phone 780.427.8640.

Personal Information

Social Insurance Number (re q u ire d fo r proce ssin g)

Last Name (cu re n t fu ll legal n am e ) Please use u pp e r and lo w e r case. First Name and One Initial (c u rre n t fu ll leg a l nam e)

Mailing Address (In c lu d e A p t. o r B o x N u m b e r) City/Town

Pro vinee Pos al Code Area Code Telephone Number

Date of Birth Gender Email Address

M F
____ l____ ____ i____ ____ i____ i____ i____
day month year

CITIZENSHIP (check one)

] CANADIAN CITIZEN or Q PERMANENT RESIDENT (Landed Immigrant)
Note: Include a photocopy o f permanent resident card or immigration long form. Visa students arc not eligible.
CITIZEN OF UKRAINE

Continuous Resident in Alberta from: Continuous Resident in Ukraine from:

month/year: __________________ month/year: ____________________

POST-SECONDARY EDUCATION
Highest degree completed:

Current institution: Name of program:

OR Last institution attended: Name of program:

Application Deadline: February 1

Deadline for submitting academic transcripts and references is February 15

Page 628
 Education Information
(Note: This award is for graduate study: Doctoral or Master level)

Name of institution you will attend this fall? Program of study:

Level of study: (check one) Anticipated date of completion:

J Masters |___|ph.D. ____ 1____ 1
____ 1____ 1____ 1____
month year
What is your Thesis or Project title? List other scholarships you are applying for:

Please submit a resume and include the following: all Universities, Colleges or Technical Institutes attended to date, including
current institution; list scholarships, awards and other forms of achievement received; indicate any publications, if any, such as
the name of the journal they were published in, also include, if applicable, any presentations/performances/exhibitions (dates,
locations, etc.).

Essay Question

Title of your proposed program of study

In two pages or less, please provide a detailed description of your proposed program of study, why you are
pursuing your research (if applicable) and what you plan to accomplish during and after your studies.
Please attach these pages to your application. Pages must be single-spaced, and enough space between the lines
for legibility, approximately six lines per vertical inch. Font size should not be less than 10 and condensed type
is not acceptable.

Application Deadline: February 1

Deadline for submitting academic transcripts and references is February 15
 References

Name the two individuals who will be submitting a letter of reference. Note to Referees: since there arc a number of
applicants competing for a limited number of awards, it is important that you provide as much detailed information on the
applicant’s background, program of study, accomplishments and area of research.

Name Position Held

Institution

Name Position Held

Institution

Below, list the institutions you are requesting transcripts from (include your surname if it is different on the transcript). If
you applied last year and wish to use the same transcript, please indicate the specific transcript(s).

Page 630
 Declaration of Applicant
I have read and understand the instruction, and declare that
a. all information provided is true and complete and I understand it is subject to audit;
b. I will be a full-time student at the institution named for the period stated;
c. I will immediately notify the office of Alberta Scholarship Programs in writing if I
withdraw from full-time studies before completing one semester of studies.
I understand and agree that
a. my personal information pertaining to my post-secondary academic record may be released
and exchanged by and between Alberta Scholarship Programs and the educational
institution for the purpose of determining my eligibility for a scholarship;
b. my personal information pertaining to my post-secondary academic enrolment status may
be released and exchanged by and between Alberta Scholarship Programs and the
educational institution for the purpose of determining my eligibility for a scholarship;
c. my personal information may be released and exchanged by and between Alberta Scholarship
Programs and any provincial government departments, boards or institutions to verify the
information I have provided to Alberta Scholarship Programs and for the use in research and
statistical analysis in program evaluation.
I understand and agree that
if I receive a scholarship my name, award and city/town may be released publicly to
promote the program, however, this is not a criterion for eligibility, and if I do not want to
be identified, I will contact Alberta Scholarship Programs.

Signature of Applicant (in ink) Today’s Date (in ink)

Complete package must be postmarked no later than February 1.

Official transcripts and references must be postmarked no later than February 15.
Notification of results may be expected in May.

THE ALBERTA HERITAGE SCHOLARSHIP FUND

Funded by a $100 million endowment from the Alberta Heritage Savings Trust Fund, the Alberta Heritage Scholarship Fund
is designed to stimulate the pursuit of excellence by recognizing outstanding achievement and by encouraging and assisting
Albertans to achieve their fullest potential.

Alberta Scholarship Programs administers another graduate scholarship, the Arts Graduate Award for Master level study in the field of
the Arts. Information on this scholarship is available on our website.

For information on other awards administered by Alberta Scholarship Programs

visit our website; alis.alberta.ca/scholarships
 AUDIT NOTES & EXPLANATIONS

Social Insurance Number

STUDENT’ NAME:

DATE:

REASON FOR REVIEW: □ Audit O Other

□ Appeal

W/P
REF.
NOTES EXPLANATIONS

Page 632
 Imprimer le formulaire

yQdhwbc^n Demande de la subvention du regime

Alberta Centennial Education Savings Plan
Ce formulaire doit etre rempli par le ou les souscripteurs d'un regime enregistre d'epargne-etudes (REEE) ou regime d'epargne-etudes pour lequel une demande
d'enregistrement sera presentee. Vous devez remplir un formulaire separe pour chaque beneficiaire et pour chaque type de subvention demandee, et le soumettre a un
promoteurde REEE.

Genre de subvention (cocher celle qui convient)

subvention de 500 $ Q subvention de 100 $ (8 ans) Q subvention de 100 $ (11 ans) __ subvention de 100 $ (14 ans)

Partie A - Information sur le beneficiaire

Nom Prenom ou prenoms Date de naissance Sexe
(aaaa/mm/jj)
@ 0
Partie B - Preuve de residence en Alberta
Adresse du parent ou du tuteur legal Citd/ville/municipalite Code postal

Je ou nous comprenons qu'un parent ou le tuteur legal doit repondre aux exigences en matiere de lieu de residence en Alberta pour
que la subvention soit versee dans le REEE d’un beneficiaire.
□ Je, _____________________________________________________________ affirme etre le parent ou le tuteur legal du beneficiaire
IMPRIMER le nom du parent ou du tuteur legal
et j'ai fourni des preuves d'identite et de residence qui repondent aux exigences en matiere de lieu de residence en Alberta,
OU
] J'ai fourni une preuve d'identite confirmant que , un parent ou le tuteur
IMPRIMER le nom du parent ou du tuteur legal
legal du beneficiaire, repond aux exigences en matiere de lieu de residence en Alberta.
A etre rempli par le Indiquer le genre de preuve d'identite et de residence qui demontre que le parent ou le tuteur legal repond aux exigences
promoteur de REEE en matiere de lieu de residence en Alberta.

Partie C - Criteres additionnels pour la subvention de 100 $

] Je confirme que le beneficiaire est inscrit ou a ete inscrit au moment approprie a I'ecole suivante :

Nom de I'dcole Citd/ville/municipalitd et province de I'dcole

^ Je confirme qu'au moins 100 $ ont ete deposes dans le REEE du beneficiare (en plus de la subvention du regime Alberta
1 Centennial Education Savings Plan, de la Subvention canadienne pour I’epargne-etudes, et du Bon d’etudes canadien) dans les 12
derniers mois.
Partie D - Je ou nous autorisons que le promoteur demande au fiduciaire de faire la demande de la subvention au nom du
beneficiaire :
IMPRIMER le nom du souscripteur Signature du souscripteur Date (aaaa/mm/jj)
X
IMPRIMER le nom du co-souscripteur (s'il y a lieu) Signature du co-souscripteur (s'il y a lieu) Date (aaaa/mm/jj)

Avis de collecte, d'utilisation et de divulgation de I'information personnels

Les renseignments personnels sur ce formulaire sont recueillis conformement aux lois suivantes :
■ Alberta Centennial Education Savings Plan Act (Alberta)
■ Alberta Centennial Education Savings Plan Regulation (Alberta)
■ Loi de I'impdt sur le revenue (Canada)
aux fins de I’administration du regime Alberta Centennial Education Savings Plan par I'Alberta Innovation and Advanced Education,
Emploi et Developpement social Canada ainsi que I'Agence du revenu du Canada.
La collecte, I'utilisation et la divulgation de renseignements personnels sont conformes aux lois suivantes :
■ Freedom o f Information and Protection o f Privacy Act (Alberta)
■ Loi sur la protection des renseignements personnels (Canada)
■ Loi sur la protection des renseignements personnels et les documents electroniques (Canada)
Toute question au sujet de la collecte de I'information fournie peut etre envoyee au gestionnaire du regime Alberta Centennial
Education Savings Plan, en appelant au numero sans frais 1-866-515-ACES [2237] ou en envoyant un courriel a I’adresse

Signature du parent ou du tuteur legal du bdneficiaire pour qui les preuves d’identite et de residence qui ont dtd fournies Date
repondent aux exigences en matiere de lieu de residence en Alberta )(
Signature du parent ayant la garde ou du tuteur legal (s'il differe de la signature ci-dessus) Date
X
Signature du souscripteur (s’il differe de la signature ci-dessus) Date A usage No du REEE
interne
X seulement
ACES1 (Rev. January 2014) Page 633
 Retour au formulaire

Explication des mots cles

La « subvention du regime Alberta Centennial Education Savings Plan » o u « subvention » fa it re fe re n c e

a u n e s u b v e n tio n p a y a b le e n v e rtu d e I'A lb e rta C e n te n n ia l E d u c a tio n S a v in g s P la n A c t (A lb e rta ) e t d u A lb e rta
C e n te n n ia l E d u c a tio n S a v in g s P la n R e g u la tio n (A lb e rta ).

« Exigence en matiere de lieu de residence en Alberta »

(a ) E n c e q u i a tra it a la s u b v e n tio n d e 5 0 0 $, le p a re n t o u le tu te u r le g a l
(i) e ta it un re s id e n t d e I'A lb e rta a u m o m e n t d e la n a is s a n c e o u d e I'a d o p tio n d e I'e n fa n t ou
(ii) e s t un re s id e n t d e I'A lb e rta a u m o m e n t d e la d e m a n d e d e s u b v e n tio n .

(b ) E n ce q u i a tra it a la s u b v e n tio n d e 1 0 0 $, le p a re n t o u le tu te u r le g a l
(i) e ta it un re s id e n t d e I'A lb e rta lo rs q u e I'e n fa n t a a tte in t I'a g e d e 8, 11 o u 14 a n s , s e lo n le
c a s ou
(ii) e s t un re s id e n t d e I'A lb e rta a u m o m e n t d e la d e m a n d e d e s u b v e n tio n .

Le « beneficiaire » fa it re fe re n c e a la p e rs o n n e q u i re c e v ra d e s m o n ta n ts d 'a rg e n t p o u r s e s e tu d e s
p o s ts e c o n d a ire s (p. e x. c o lle g e , u n iv e rs ite o u e c o le d e m e tie r), s 'il e s t a d m is s ib le e n v e rtu d 'u n R E E E . L e s
m o n ta n ts d 'a rg e n t re g u s d 'u n R E E E s o n t d e s ig n e s d e s p a ie m e n ts d 'a id e a u x e tu d e s .

Le « parent ayant la garde ou le tuteur legal » fa it re fe re n c e a u n e p e rs o n n e , un m in is te re , u n e a g e n c e o u

u n e in s titu tio n q u i a la re s p o n s a b ilite d e s s o in s d 'u n e n fa n t e t a le d ro it le g a l d e p re n d re d e s d e c is io n s a s o n
s u je t.

Un « resident de I'Alberta » fa it re fe re n c e a un p a re n t ou a un tu te u r le g a l
(a ) q u i a le g a le m e n t le d ro it d e d e m e u re r a u C a n a d a e t
(b ) d o n t la re s id e n c e e s t en A lb e rta e t q u i s e jo u rn e o rd in a ire m e n t d a n s c e tte p ro v in c e .

« REEE » e s t I'a c ro n y m e d e re g im e e n re g is tre d 'e p a rg n e -e tu d e s .

Le « promoteur de REEE » e s t la p e rs o n n e o u I'o rg a n is m e q u i o ffre un R E E E a u p u b lic e t q u i o u v re un R E E E

p o u r un s o u s c rip te u r. L e s in s titu tio n s fin a n c ie re s , te lle s q u e le s b a n q u e s e t le s c a is s e s p o p u la ire s , a in s i q u e
le s c o u rtie rs o ffra n t d e s re g im e s c o lle c tifs e t le s fo u rn is s e u rs d e s e rv ic e s fin a n c ie rs p e u v e n t e tre d e s
p ro m o te u rs d e R E E E .

Le « souscripteur/co-souscripteur » fa it re fe re n c e a u n e p e rs o n n e o u a u n e a g e n c e d e g a rd e q u i o u v re un
R E E E , d e s ig n e un o u p lu s ie u rs b e n e fic ia ire s e t d e p o s e d e I'a rg e n t e n le u r n o m (d e s c o tis a tio n s ) d a n s un
REEE.

Le « fiduciaire » e s t u n e in s titu tio n fin a n c ie re q u i a d m in is tre le s fo n d s d e p o s e s d a n s le s R E E E a u n o m du

b e n e fic ia ire . Le fid u c ia ire in v e s tit, a d m in is tre e t re p a rtit le s fo n d s d e p o s e s .

NOTE : Ces explications sont presentees a titre d'information seulement. En cas de divergence, les
definitions enoncees dans I'Alberta Centennial Education Savings Plan Act (Alberta), la Loi
canadienne sur I'epargne-etudes (Canada), la Loi de I'impot sur le revenu (Canada) et les
reglements connexes ont preseance.

ACES1 (Rev. 2007/08)

Page 634
 Acrobat Reader 7.0 is required to complete & save this form.

Liberia Advanced Education

and Technology Conference / Event Profile

Form Prepared By
Name

Business Area Phone Number (including Area Code)

Funding Request_________
How much funding is being requested? How much is the ministry recommending for sponsorship?

Funded by

Event Information
Event Name

When will the event take place? Where will the event take place? How many attendees are expected?

What is the scope of the event (regional, provincial, national, international)?

Provide a brief (2 or 3 sentence) explanation of the purpose for the event.

What is the overall estimated budget for the event? Will the support requested from Alberta Advanced Education &
Technology constitute more than 50% of the budget for the
event?

Are government representatives invited to attend or speak at the event? Please provide details.

Are Advanced Education & Technology staff planning on attending this event? If so, please indicate the name(s) of person(s) who
would attend. Are complimentary delegate registrations included in the sponsorship request?

Applicant Information
Legal Name of Applicant Organization

Mailing Address

RD0001 (2009/01) Ffiggec835

 City Province Postal Code

Contact Person Phone E-mail

Type of Organization Other (please specify)

Does the organization requesting the sponsorship receive core funding (i.e. operational funding) or support for specific activities
from the provincial government? Please provide details.

Other Sponsoring Organizations

Is the current event receiving sponsorship support from other provincial government departments, or other provincial research
organizations (i.e. Alberta Research Council, iCORE, Alberta Ingenuity Fund, Alberta Heritage Foundation for Medical Research)?
Please provide details.

If funding is also being provided from other Government of Alberta (GOA) entities, please provide either:
An estimate of the total An estimate of the total GOA support
GOA support for this event based on overall budget
%

Risk
Has Advanced Education & Technology supported previous events from this organization? If yes, please provide details and, if
available, attach a copy of the previous year’s Sponsorship Reporting Form submitted by the organization after the event.

Provide details on whether or not this organization has organized this current event/conference in the past and, if so, for how many
years?

Are other funding sources secure? Please provide details.

Please indicate the level of risk for supporting this event? | |Low Q] Medium | |High
If high, how do you plan to manage the risk?

Purpose of Sponsorship Funds

Will Advanced Education & Technology receive recognition (website, promotional material, etc.) for supporting the event? Please
provide details.

Will the event increase the profile of Alberta's commitment to innovation and/or education within or outside of Alberta? Please
provide details.

RD0001 (2009/01) Ffiggec836

 Who is the targeted audience for this sponsorship request (e.g. elementary, junior high school students, secondary students, post­
secondary students; postdoctoral fellows and researchers, industry representatives, etc.)?

Relationship to Ministry Business Plan Goals

What advanced Education & Technology goals does this Does the event pertain to a priority sector(s) identified in
event correspond to? Select all that apply. the business plan? Select all that apply.
Goal 1: Alberta advanced learning and research capacity Technology Commercialization |
aligns with learner and labour market demand and
serves the needs of knowledge-intensive society. Increase Post-Secondary Spaces |
Goal 2: Albertans are able to participate fully in lifelong ,— ,
An Affordable Learning System |
learning. I— I

Goal 3: Alberta has an affordable advanced learning system Q Research and Innovation |

Goal 4: Alberta research capacity supports enhanced Roles and Mandates Policy Framework |
excellence in research and innovation in strategic □
areas Building and Educating Tomorrow’s Workforce |

Goal 5: Value is captured from research and innovation Health Care Professionals |

Comments

Other Relevant Information

What is the benefit for Advanced Education & Technology of sponsoring this event?

What is the downside of not sponsoring the event?

Recommendation
Amount
Recommend Event
Sponsorship □
Rationale
Do Not Recommend
Event Sponsorship □

Recommended by Director of
Branch / Program
Name (please print)

Signature Date

Reviewed by the
Conference Sponsorship Committee: Date of Review

RD0001 (2009/01) Ffiggec837

 Cheque Issued to
Legal Name of Recipient:

Address:

BU Account Fund Org Program Project Amount

- Select - SR-0

Remittance Message (Required) AR#

Reset

RD0001 (2009/01) FRgged338

 Acrobat Reader 7.0 is required to complete, save & submit this form.

Liberia Advanced Education

and Technology Financial Accountability Report
University Research and Strategic Investments (URSI) - Grant Programs
(Effective May 1, 2007)
This form is to be completed annually for all Alberta Advanced Education and Technology (AET) ASRIP/SEGP/SRI projects up
to and including the year of project completion. For the Final Financial Report, provide accounting for all revenues and
expenditures from inception to the end of the project.

Part 1 - General Information

Name of Institution

Project Name

Report Period
Is this the Final Financial Report? Q Yes LJ No

Agreement # AET Awarded $

URSI - Total Project Cost
Start Date End Date

Part 2 - Project Update

Project Status: Please briefly outline the current status of the project as of the end of the reporting period (e.g. waiting to
secure balance of funding, implementation underway, final report/implementation completed). If applicable, provide a brief
explanation.

If there have been any significant changes to the original proposal, or to plans for implementation, provide details.
Please Note: AET must approve for significant deviations from the original proposal.

Note: Any extension must obtain approval from URSI 3 months for project with pending payment for 3 weeks for project with
no pending payment prior to the due / end date(s) specified in the Grant Agreement.

Part 3 - Financial Information

Interest Earned* on Investment of AET Grant

Were any of the AET grant proceeds invested during the reporting period? | | Yes Q No

If so, please indicate the total interest earned amount $

Comments

Note: Any interest earned must be spent on the approved proposal according to the Grant Agreement Terms

RD0002 (Rev. 2008/04) PagPdgtf 639

Summary of Secured Funding
Please Note: This table should be completed and/or updated until all funding for the project is secured.
Include all funding commitments for the entire course of the project which have been secured as of the reporting period. These
commitments need not have been received as revenues in the current reporting period. If all funding for the project was reported as
secured and finalized in a previous financial report, then please indicate so by noting this on the form rather than completing this
section again.

Forecast per Revised

Source of Eligible Contributions Original Total for Actual to Forecast for Future Year(s)
Proposal Project

C=Cash l=lnkind T=Total to to

(Cumulative)
AET Contribution Awarded as per
Grant Agreement
C
Interest Earned from AET's Grant
C
C
Other (specify) 1

H Add a Row

C
Remaining Funds to be Secured
1

C
TOTAL CONTRIBUTIONS 1

If there are any remaining funds to be secured, list source(s), outline plans and timelines for obtaining them.

If any secured is conditional, or if sources of funding have changed, provide details.

RD0002 (Rev. 2008/04) PagPagtf 640

Summary of Eligible Project Expenditures
From all funding sources, list the eligible expenditures that have been made during the reporting.
(Note: For projects that are receiving their ASRIP grant in installments, total expenditures for the period should be significant
enough to warrant the release of subsequent installments.)
Forecast per Revised
Eligible Expenditures Original Total for Actual to Forecast for Future Year(s)
Proposal Project

C=Cash l=lnkind T=Total to to

(Cumulative)
Purchase of equipment or facility
C
(includes shipping, taxes, and
installation) I

C
Lease of equipment or facility
I

Personnel (for infrastructure C

development only)
I

C
Components
I

C
T ravel
I

C
Software
I

C
Extended Warranty
I

Construction or Renovation C
(research related)
I

Training of Infrastructure C
Personnel
I

C
Other (specify) I
Add a Row

C
TOTAL EXPENDITURES I

RD0002 (Rev. 2008/04) PagPSgg 641

Comments: (Please provide an itemized list for expenditures as listed above).

If applicable, outline plans for the expenditure of any as yet unexpected funds.

RD0002 (Rev. 2008/04) PagPggri 642

Part 4 - Signatures
We hereby verify that this report is accurate and that the proceeds of the AET grant are being utilized in accordance with the
guidelines of the program. We also certify that itemized records of expenditures on the project are being maintained by the university
and are available for audit purposes.

VP Research or Designate Financial Officer

Name Name

Title Title

Phone Phone

E-Mail E-Mail

Signature Signature

Date Date

Reset Form Save Print

RD0002 (Rev. 2008/04) PagPSgtf 643

^4lb erfcfcJi Student Aid Alberta
Award Value - $2,000 per semester
The Indigenous Careers Award is designed to encourage Indigenous Albertans (First Nations, Metis, and Inuit) to pursue and complete post­
secondary studies in certificate, diploma, applied degree, and bachelor’s degree programs that lead to high-demand career outcomes in Alberta.
Indigenous Ancestry and Residency Requirements
You must be Status Indian/First Nations, Non-Status Indian/
First Nations, Metis, or Inuit and be able to provide proof of
Indigenous ancestry.
You must be a Canadian Citizen or Permanent Resident
of Canada and an Alberta resident.
Eligible School Requirement
In order to use this application, you must be attending
Maskwacis Cultural College.
If you are a co-op student, a student in a brokered program,
or participating in an official exchange and the school that
will issue your post-secondary credential is NOT Maskwacis
Cultural College, then you must apply through the school that
will issue your credential.
Course Load and Study Requirements
You must be enrolled in the 2015-16 winter semester
in order to be considered for these awards.
You must be enrolled in at least 60% of a full course load.
If you are a student with a documented permanent disability,
you can be eligible if you are enrolled in at least 40% of a full
course load.
Your school determines what constitutes a full-time course
load in each program.
Co-op students, students in brokered programs, and students
who are participating in an official exchange may be eligible.
You must be in satisfactory academic standing as determined
by your school - satisfactory academic standing may vary in
how it is determined by school or program.
You are not eligible to receive the award if you:
- switch your program of study from an eligible program
to an ineligible program before the award is paid, or
- withdraw from studies or drop from full-time to part-time
studies before the award is paid.
Credential Types
You must be enrolled in a certificate, diploma, applied or
bachelor's degree program. Students enrolled in apprenticeship
technical training, integrated training, pre-employment or
non-credential programs are not eligible.
University transfer programs are only eligible if they are
in the program bands described in the right hand-column.
E.g. General university transfer programs would not be
eligible but an education transfer program that leads directly
to a Bachelor of Education program would be eligible.
Indigenous Careers Award
Number of Awards Issued
If the number of eligible applicants exceeds the funding
available for this award, a selection committee made up of
members from Maskwacis Cultural College and Student Aid
Alberta will decide which applicants will receive the award.
Eligible Programs of Study
Eligible program bands are based on Government of Alberta’s
forecast of high-demand careers in Alberta. The program
bands are:
• Business
• Education
• Physical, Natural & Applied Sciences
• Technologists
Programs that fail within these program bands are eligible
if they lead to careers in the following:
- Finance
- Accounting
- Marketing
- Business administration and management
- Communications technologists and technicians
- Elementary and secondary teaching
- Teaching related fields
- Early childhood education and childcare
- Natural resources and conservation
- Engineering and engineering-related fields
- Computer and information sciences
- Agriculture
- Architecture and urban planning
- Biological sciences
- Physical sciences
- Mathematics and statistics
- Science technologists and technicians
- Mechanic and repair technologists and technicians
- Precision production
Program Bands Not Eligible
The following program bands are not eligible:
• Health Sciences
• Languages, Social Sciences, Arts & Humanities
• Legal & Security
Deadline and How to Apply
The application deadline is February 12, 2016.
Submit your completed application to Student Aid Alberta.
Remember to include a copy of proof of your Indigenous ancestry
with your application. Do not submit original documents.
Student Aid Alberta
PO Box 28000 Station Main
Edmonton AB T5J 4R4
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 Student Aid Alberta Indigenous Careers Award

FOIP Collection Notice

Advanced Education is collecting the personal information on this form under the authority of section 33(c) of the Freedom of
Information and Protection o f Privacy A ct (FOIP Act), as being directly related to and necessary to determine your eligibility for the
Indigenous Careers Award under the Student Financial Assistance A c t and to administer scholarships including research, statistical
analysis and program evaluation. The use and disclosure of your personal information is managed in accordance with the FOIP Act.
If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll
free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, PO Box 28000
Station Main, Edmonton AB T5J 4R4.

Indigenous Ancestry

Please indicate your Indigenous Ancestry:

I 1 Status Indian/First Nations Q Non-Status Indian/First Nations Q Metis Q Inuit

Documentation Requirements: You must provide proof of your Indigenous ancestry with your application. Acceptable documents
of proof include a copy of one of the following (do not submit original documents):
• certificate of Indian Status, a status card or a valid band • a certified copy of a Nunavut Trust Certificate card
membership card or Inuit beneficiary card
• letter from your band verifying your status • letter of support from Aboriginal Affairs and Northern
• Metis membership card or letter issued by the Metis Nation Development Canada (AANDC) or Nunavut Tunngavik
you are registered with Incorporated
• letter or membership card from the Metis Settlements • for a non-status person, a letter of support from a First
General Council Nations, Metis or Inuit organization

Other proof of Indigenous ancestry will be assessed on a case-by-case basis.

Personal Information

Last Name (current full legal name) Social Insurance Number

I I I I I I I I I I I I I 1 I I I I I I I I I I
M id d le
First Name (current full legal name) In itia l
Gender Q Male Q Female
I I I I I I
Apartment or Box Number
I I I I I I I I I □ Birthdate Day Month Year

, I _ I______ l _ 1 i
I I II I I I I I II I I I I 1
Street Address Are you an Alberta resident*? □ Yes □ No
* You are an Alberta resident if one o f the following describes
I I I I I I I I I I I I I I I I I your situation:
City/Town • You maintained permanent residence in Alberta for
a period o f 12 months immediately p rior to attending
I I I I I I I I I I I I I I I I I
a post-secondary school, o r
Prov/State Country Postal/Zip Code
• Your parents o r guardians have maintained permanent
residence in Canada for 12 consecutive months and
Mobile Number (format: 999-999-9999) to receive text messages reside in Alberta, o r
• Your spouse /partner is an Alberta resident, o r
J__L • You have been declared, o r fall within a class o f persons
Telephone Number (format: 999-999-9999) declared, to be a resident in Alberta by the Minister.

I I I I I I I I Alberta Student Number (if known)

Email Address

Citizenship Status: (check one)

□ Canadian Q Permanent Resident |_) Protected Person

INDIG ENO US CAREERS A W A R D - M a s k w a c is C u ltu ra l C o lle g e - L a s t re v is e d D e c e m b e r 2 0 1 5

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 Page 2
F u ll-tim e S tu d ie s In fo rm a tio n

Name of School

M|A|S|K|W|A|C| I | S [ | C| U| L| T| U| R| A| L| | C| 0| L| L|E|G|E|
Program

I I I I I I I I I .......................... I I I I I I I I I ......................
Program Specialization/Major

t i 1 1 I 1 L 1 1 i L I I 1 J _L I I I .1. I I I I
Program Outcome What year of this program will you be in? (check one)
Q Certificate □ 1st year or less Q 2nd year Q 3rd year Q 4th or 5th year
n Diploma
Length of your program of studies (check one)
□ Degree l~ i 1 year or less Q 2 years Q 3 years I 1 4 or 5 years

Enter your program session start and end dates for the current school year.

Start End
Day M onth Year Day M onth Year

i J _____ L I
___ ___ _ ] ___ J _____ L I
___ ___

D e c la ra tio n o f A p p lic a n t

I have read and understand the instructions, and declare that:
• all information provided is true and complete and I understand
it is subject to verification.
I agree to:
• immediately notify Student Aid Alberta if there are any changes
to the information I have provided in this application.
• provide information or documents as requested by Student
Aid Alberta to verify any statements made in this application.
• use any financial assistance provided to pay my academic
fees first; then I will pay other educational and living costs
associated with my program of studies.
I understand that:
• personal information pertaining to my enrollment and program
status will be released and exchanged between Student Aid
Alberta and Maskwacis Cultural College for the purpose of
determining my eligibility for the Indigenous Careers Award.
• personal information may be released and exchanged
between Student Aid Alberta and any provincial government
department, board, or agency to verify the information I have
provided to Student Aid Alberta.
• I may be denied financial assistance if I fail to notify Student
Aid Alberta in writing of any change in my academic status
or study period, or fail to provide documents or information
as requested by Student Aid Alberta to verify statements
made in this application.
• if I make a false or misleading statement in this application
I may be denied financial assistance, and/or required to
immediately repay all financial assistance received, and/or
subject to criminal prosecution.
• failure to disclose information or provide updated information
as requested by Student Aid Alberta may constitute the
making of a false or misleading statement.
I understand and agree that;
• if I receive a scholarship my name, award, and city/town may
be released publically to promote the program. My name, the
name of the scholarship and the scholarship amount may also
be published on the Government of Alberta Grant Disclosure
Portal. However, my consent to the publication of this personal
information is not a criterion for eligibility, and if I do not want
to be identified, I will contact Student Aid Alberta and request
that it not be disclosed.

Signature of Applicant (in ink) Today’s Date (in ink)

Day M onth Year
X
_ u 1 1 1 1 ! 1

OFFICE USE ONLY

131 13 1 2
GRANT TOTAL AWD INSTIT PGM DA MO YR DA MO YR ORG ADD
Disbursement
E
MO YR AUTHORIZATION AWARD KEY APP KEY

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