Personal Details (NAME MUST BE AS IT APPEARS ON YOUR PASSPORT)

Name: *

Middle Name:

Surname: *

Date of Birth:

Gender

Address: (PRINTED ON LETTER)

House/Apt # *

Street: *

Province/State: *

City: *

Postal Code: *

Country: *

Mailing Address: (IF DIFFERENT)

House/Apt #

Street:

Province/State:

City:

Postal Code:

Country:

Passport Number: *

Telephone: *

Applicant Email: *

First Language:

Country of Citizenship: *

Emergency Contact Name:

Relationship:

Contact Telephone:

Contact Email:

Agent Information

Are you working with an agent?

Yes No

Agency Name:

Agency Contact Person:

Agency email address:

Program Information

What program are you applying to? *

Start Date: *

Additional program

Start Date: *

English Proficiency

Name of English test taken:

English test score:

Date of test taken or to be taken:

Upload your required documents

Credit card details for $100 application fee

Please note that your credit card will not be charged now. CAD$100 will be charged by Georgian College once your full application package has been received. If you have any questions or concerns, please contact Georgian@ilac.com

Credit Card:

Payable to Georgian College

MasterCard / VISA Amount Paid:

$100

Cardholder Name:

Credit Card #:

Expiry Date: (YY / MM)

Security Code:

Waiver Code

Address: (PRINTED ON LETTER)

Mailing Address: (IF DIFFERENT)

Thank you for submitting your application. We will get back to you ASAP.