Gateway Program Application

1 2 3 4 5 6 7 8 9 10 11 12

Personal Information

Family Name(s):*

Given Name(s):*

Age:*

Date of Birth:*

Gender:*
Male
Female

Citizenship:*

First Language:*

Student Address

Street Address:*

City and Province:*

Country:*

Postal/Zip Code:*

Phone Number:*

Personal Email Address:*

Agency Information (if applicable)

Agency Name:

Agent Name:

Agent Email:

Agent Phone Number:

Program Requirements *

Please send me the CultureWorks placement test to determine if I am eligible for the Gateway Program.

I have an official language test score available.

Test Type*

Please Specify:*

Overall Test Score:*

Choose Your Pathway:*

ESL Only (I’m only interested in the Gateway Program for now).
I would like more information regarding conditional acceptance to Canadian Universities/Colleges through CultureWorks.

Start Date: *

Program Length:*

Degree of Interest (if applicable):

University/College Program of Interest (if applicable):

Educational Background

Highest Level of Education Completed (high school, college, university): *

Name of High School:*

City:*

Country:*

From:*(month/year)

To:*(month/year)

Graduation certificate awarded:*
Yes
No

Name of College/University (if applicable)

City:

Country:

From: (month/year)

To: (month/year)

Diploma/Degree awarded:
Yes
No

Educational Background Disclaimer:*By checking this box, I certify that I have disclosed all educational institutions I attended. During any period of time not accounted for, I was/am not in attendance at any educational schools. I understand that any misrepresentation of this information may result in the cancellation of my application, admission or registration to a post-secondary school.

Refund & Privacy Policies: *
I understand that it is my responsibility to read the school policies [1] posted on the website. The terms and conditions of the refund policy [2] on the website. *
By checking this box the applicant agrees and understands.

Student Signature:*

Date:*