Exchange Application - Incoming - Brescia University College

Title(Ms., Mrs., Miss., Mr.)

First Name*

Last Name*

Middle Name(s)*

Have you previously applied to Brescia University College/Western University?*

Yes

No

Have you previously been a student at Brescia University College/Western University?*

Yes

No

Permanent Address

Country *

Province/State*

City*

Address*

Postal/Zip Code*

If you mailing address is different than your permanent address, please complete the following section.

Country

Province/State

City

Address

Postal/Zip Code

Personal Information

Phone Number*

Email Address*

Date of Birth*

First Language*

Martial Status*

Gender*

Country of Birth

Country of Citizenship *

Country of Residence (include years)*Eg. Canada for 20 years.

Do you have a disability?*

Yes

No

This information is needed in case special facilities are required.

If yes, please explain.

Current Academic Program Information

Home University *

Academic Program*

Program Level/Year*

Length of Program *Years.

Academic Details for Exchange

Period of Study*

Full-Year (September - April)

Fall Term (September - December)

Winter Term (December - April)

Year*

2020

2021

2022

2023

Level of Study *

Year Two

Year Three

Year Four

Residence Accommodation

Do you want to live in residence (Clare Hall) at Brescia?*

Yes

No

Do you need more information on off-campus housing options?*

Yes

No

Emergency Contact Information

Title*(Ms., Mrs., Miss., Mr.)

First Name*

Last Name*

Relationship to Student *

Country *

Province/State*

City*

Address*

Postal/Zip Code*

Cell Phone Number*

Work Phone Number*

Email Address*

Agreement

Upon the completion of my Exchange Program at Brescia University College, I request that a final copy of my Academic Record from Brescia University College be sent to my home University.

Name*

Date*

I hereby certify that all the information provided on this application is true and complete. I understand that otherwise my admission to or registration in the University may be revoked.

Name*

Date*