Full name, as it appears on valid credentials.

First name

Middle name

Last or Family name

Full verifiable Home and Mailing address. If P.O. Box is mailing address, home address is still required:

Home address:

Mailing address:

Telephone numbers:

Highest level of Educational Achievement:

Name of Post Secondary Institution:

Address of Post Secondary Institution:

Level Completed including degree granted:

Name of High School attended:

Address of High School attended:

Years attended:

Work Experience if applicable:

Name of employer

Address of employer

Position

Length of employment

Academic and Career Interests e.g. Engineering, Teaching, Computer Science, etc.

Reason for choosing these fields:

Please note that this is a preliminary request form. No fee is charged. Once qualified, a full application form and applicable fee will be required before the application is processed.