POLYTECHNIQUE MONTRÉAL - PDF

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POLYTECHNIQUE MONTRÉAL ADMISSION READMISSION PROGRAM CHANGE (2 nd and 3 rd cycles) ADMISSION SEMESTER: FALL WINTER SUMMER PROGRAM OF STUDY UNDERGRADUATE GRADUATE CONTINUING EDUCATION Bachelor s (engineering

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POLYTECHNIQUE MONTRÉAL ADMISSION READMISSION PROGRAM CHANGE (2 nd and 3 rd cycles) ADMISSION SEMESTER: FALL WINTER SUMMER PROGRAM OF STUDY UNDERGRADUATE GRADUATE CONTINUING EDUCATION Bachelor s (engineering degree) PhD Microprogram 2 nd cycle Certificate Research-Based Masters Independent (graduate) Microprogram 1 st cycle Independent (undergraduate) Professional Masters Audit (graduate) Independent (certificate) Audit (undergraduate) DESS Audit (certificate) Family name (maximum 40 characters) 1 Given name (maximum 25 characters) 2 Date of birth MONTH DAY Permanent code (Ministère de l éducation du Québec) SEX: MALE FEMALE (OPTIONAL) HAVE YOU PREVIOUSLY ATTENDED POLYTECHNIQUE MONTRÉAL? YES NO 3 IF YES, ID NUMBER PROGRAM HAVE YOU PREVIOUSLY APPLIED TO POLYTECHNIQUE MONTRÉAL? YES NO IF YES, PROGRAM MOTHER TONGUE (FIRST LANGUAGE LEARNED) LANGUAGE USED (LANGUAGE SPOKEN AT HOME) CITY AND COUNTRY OF BIRTH CITIZENSHIP (IF OTHER THAN CANADIAN) 4 FRENCH ENGLISH OTHER FRENCH ENGLISH OTHER CITY OF BIRTH STATUS IN CANADA CANADIAN CITIZEN PERMANENT RESIDENT STUDENT VISA OTHER COUNTRY OF BIRTH MAILING ADDRESS PERSON TO CONTACT IN CASE OF AN EMERGENCY NUMBER, STREET, APARTMENT 5 CITY PROVINCE, COUNTRY POSTAL CODE ( ) ( ) HOME TELEPHONE WORK TELEPHONE EXT. 6 FAMILY NAME GIVEN NAME RELATIONSHIP TO APPLICANT ( ) ( ) HOME TELEPHONE WORK TELEPHONE EXT. COUNTRY OF YOUR PRINCIPAL RESIDENCE EDUCATION HISTORY (begin with the most recent) MONTH S ATTENDED 7 MONTH S ATTENDED MOINTH S ATTENDED PROGRAM SELECTED (A SECOND CHOICE MUST BE INCLUDED IN THE EVENT THAT THE FIRST IS UNAVAILABLE) 8 FIRST CHOICE PROGRAM CODE NAME OF PROGRAM OPTION OR ORIENTATION (GRADUATE STUDIES) SECOND CHOICE PROGRAM CODE NAME OF PROGRAM OPTION OR ORIENTATION (GRADUATE STUDIES) EMPLOYER (IF RELEVANT) EMPLOYER S NAME DIVISION ADDRESS (NUMBER, STREET, APPT) (CITY) (PROVINCE, COUNTRY, POSTAL CODE) 9 WORK TELEPHONE ( ) EXT. PROVIDE A BRIEF DESCRIPTION OF YOUR DUTIES IF APPLYING FOR A CERTIFICATE OR IF YOU HAVE BEEN OUT OF SCHOOL FOR MORE THAN ONE SEMESTER. S OF WORK EXPERIENCE: Father s full name maximum 40 characters Given name maximum 25 characters Mother s full maiden name maximum 40 characters 10 Given name maximum 25 characters PERMANENT ADDRESS (optional) NUMBER, STREET, APARTMENT MOTHER AND FATHER CITY PROVINCE/COUNTRY POSTAL CODE MOTHER FATHER SECTIONS TO BE FILLED IN BY GRADUATE PROGRAM CANDIDATES ONLY (AFTER OBTAINING AN ENGINEERING DEGREE) PLEASE INDICATE YOUR LEVEL OF PROFICIENCY IN ENGLISH AND FRENCH IN THE APPROPRIATE FIELDS BELOW (E = EXCELLENT, G = GOOD, P = POOR) 11 LANGUAGE READ UNDERSTAND WRITE SPEAK FRENCH ENGLISH SCHOLARSHIPS AND FINANCIAL ASSISTANCE DO YOU INTEND TO ASK FOR AN INDIVIDUAL SCHOLARSHIP FOR THE PROJECTED PERIOD OF STUDY? YES NO 12 IF YES, ORGANIZATION AMOUNT $ DURATION months HAVE YOU APPLIED FOR A SCHOLARSHIP? YES NO IF YES, ORGANIZATION ARE YOU APPLYING FOR FINANCIAL AID? YES NO IF YES, IS THIS AN ESSENTIAL ADMISSION REQUIREMENT? YES NO 13 THROUGHOUT YOUR STUDIES, DO YOU INTEND TO WORK FULL-TIME? YES NO IF YES, EMPLOYER FOR REFERENCE PURPOSES, PLEASE PROVIDE THE NAMES AND ADDRESSES OF THREE FORMER PROFESSORS OR EMPLOYERS. 14 IF RELEVANT, BRIEFLY DESCRIBE ANY PREVIOUS EXPERIENCE YOU WISH TO DEVELOP THROUGH YOUR PROJECTED STUDIES (PUBLICATIONS, RESEARCH, ETC.). (USE ADDITIONAL PAPER AS NEEDED.) 15 PLEASE INDICATE THE AREA OF SPECIALIZATION YOU INTEND TO PURSUE AND THE TOPIC OR PROJECT THAT INTERESTS YOU. (USE ADDITIONAL PAPER AS NEEDED.) HAVE YOU ALREADY CONTACTED AN POLYTECHNIQUE MONTRÉAL PROFESSOR? YES NO IF YES, PROFESSOR S NAME 16 SECTIONS TO BE FILLED IN BY GRADUATE PROGRAM CANDIDATES ONLY (AFTER OBTAINING AN ENGINEERING DEGREE) I REQUEST PERMISSION TO PRODUCE MY THESIS OR DISSERTATION IN ENGLISH : YES NO THIS REQUEST IS FOR THE FOLLOWING REASONS: SECTION TO BE FILLED IN BY INDEPENDENT AND NON-CREDIT STUDENTS ONLY SEMESTER COURSE CODE CHOICE OF COURSES COURSE TITLE 17 UNDERGRADUATE GRADUATE FALL WINTER CERTIFICATE SUMMER AUTHORIZATIONS/DECLARATIONS (OBLIGATORY) Pursuant to the Act Respecting Access to Documents Held by Public Bodies and the Protection of Personal Information, I acknowledge that I have read and understood the appended document regarding student file confidentiality (Confidentiality of student files) (www.polymtl.ca/admission) and a) I authorize the transmission of information described in this appendix to the organizations listed b) I am opposed to the transmission of information to one or more organizations. If so, I must print (Confidentiality of student files) and complete a statement of objection, and send it to Polytechnique Montréal. OR Authorize OR Opposed I agree to comply with any laws, statues, regulations, policies and edicts currently in effect at Polytechnique Montréal and Université de Montréal or adopted during the course of my studies. Read 18 I acknowledge that Polytechnique Montréal is a secular public institution and consequently: A person to whom academic activities are being provided must show their face during the delivery of services ; To be allowed in some laboratories, the clothing in use must respect the law concerning health and security ; No area is designated exclusively for the practice of religion. Read By signing, I hereby authorize the processing of my file: DATE SIGNATURE Nov. 2015 APPENDIX II Confidentiality of student files Pursuant to the Act Respecting Access to Documents Held by Public Bodies and the Protection of Personal Information, any personal information provided to École Polytechnique by you or by a third party on your behalf is considered confidential, as is any information about you kept on file by the school. Only the École Polytechnique staff (services and departments) responsible for managing your studies will use this information. The information requested is vital to managing your application for the purposes of admission and/or registration. Refusal to supply any obligatory information will result in the cancellation of your application. (Note that omitting any obligatory fields in the online application will make it impossible to submit the application.) The information requested pertains to the following statements: I authorize the Quebec educational institutions I have attended, as well as the Ministère de l Éducation, du Loisir et du Sport (MELS) to transmit, through the Conférence des recteurs et des principaux des universités du Québec (CRÉPUQ), my academic results to École Polytechnique. I authorize the foreign educational institutions (outside Québec) I have attended to transmit directly my academics results to École Polytechnique. École Polytechnique has informed me that the information needed to create and validate the permanent code will be transmitted to the Ministère de l Éducation under an agreement authorized by the Commission d accès à l information. This information may be subject to verification by the Directeur de l état civil. I authorize École Polytechnique to transmit to the Conférence des recteurs et des principaux des universités du Québec (CRÉPUQ) the information required to manage admissions and to produce statistics that may entail the linkage of institutional files. I acknowledge that the information needed to manage admissions by the institution attended along with information on my citizenship status to establish my tuition fees may be subject to validation by the MELS. I authorize, where relevant, the Ministère de l'immigration et des Communautés culturelles to confirm to École Polytechnique the delivery of a Certificat d acceptation du Québec (CAQ) in my name. I declare that all information provided on the admission form and in the documents supplied (or to come) is true, correct, and complete in every respect. Note that we are bound by law to submit to a student association (one that is recognized by law and that represents you) the following information: your family and given names, address, telephone number, address and program of study. Various organizations, associations or individuals may ask us to provide lists or reports that contain personal information. Please review the list below. If you do not object to the transmission of the information described, check the appropriate box in the admission form to authorize the transmission of said information. If, however, you do object to the transmission of such information, check off the information you object to having transmitted on the statement of objection below. Detach and sign this form and include it with your application. Once you have registered at École Polytechnique, you may access the list of objections at any time and modify it as you want. Under the federal Privacy Act, individuals have the right to access personal information concerning them contained in federal government databases, including Statistics Canada. Students who do not want their personal information to be used may ask Statistics Canada to remove it from the national databases. December 15, 2010 STATEMENT OF OBJECTION (Do not submit if you have no objection) I object to the transmission of my family name(s) and given name(s), address, telephone number, address if applicable, date of birth, course of study, level of study and status at École Polytechnique. Check the appropriate section(s): a) To the student association representing me, for the purpose of publishing the student directory; b) To an organization or business, for the purpose of recruiting students and graduates or the dissemination of non-commercial information; c) To the establishment where I completed my studies; d) To the Ordre des ingénieurs du Québec; e) To the Association des diplômés de l École Polytechnique, for the purpose of communicating with me; f) In the case of a foreign student, to the Government of Canada, the Government of Québec, the granting agency or an official representative of my country, for the purpose of confirming my status at École Polytechnique or regarding the issue of a Certificat d acceptation du Québec in my name by the Ministère de l'immigration et des Communautés culturelles; g) To a granting agency or enterprise information that makes it possible to establish my eligibility for or participation in the subsidized activity or my eligibility for a scholarship; h) To a university researcher, on a confidential basis, for the purpose of pursuing his/her research; i) To the Fondation de Polytechnique for the purpose of providing me with information or solicit donations. Family name(s): Given name(s): Signature: Date: December 15, 2010
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