Application for Education Assistance
Grand River Post Secondary Education Office
 P.O. Box 339, OHSWEKEN, ON, N0A 1M0     TOLL FREE  (877) 837-5180    TEL. (519)445-2219     FAX.(519)445-4296
Email: grpseo@worldchat.com                                                                           www.grpseo.org

(SHADED AREAS FOR OFFICE USE ONLY)
Rules, Guidelines and Definitions Page
Student Information

Six Nations Registry Number


Social Insurance Number

Birth Date

Application Date
___  ___  ___  ___  ___  ___  ___  ___  ___  ___
__ __ __  __ ___ ___  ___ __ __

 		__
M		 __
D		 __
Y		     __    __   ___
     M      D      Y
Surname:_______________________ First__________________________ Second     _________________________ 
SEX:      Male ____   Female ____   Have You Been living in Canada for the last 12 months? Yes_____    No______
Home Address Address while at School Mailing Address
________________________________ _______________________________ ________________________________
________________________________ _______________________________ ________________________________
________________________________ _______________________________ ________________________________
Postal Code_______________________ Postal Code______________________ Postal Code_______________________
E:mail:_____________________________________________________________
Phone #_(_______)_____________ Phone #_(_______)_____________ Phone #_(_______)_____________
Emergency Contact Person: _________________________________________
 Phone #_(_______)_____________
Student Profile

___S1 Single living with Parents
___M1 Married/Common Law with Employed Spouse
___S2 Single living away from home ___M2 Married/Common Law with Dependant Spouse
___S3 Single Parent ___Number of Dependants (under age 18 or 18 to 21 if in high school)
Bank Deposit Information:
 Chartered Bank in Canada
 __________________
 Branch#:__________
 Account#:__________
EDUCATION PLAN

Attendance
Program Level
Graduation Date
____ Full Time   ___Level I-College ____    ____    ____
____  Part Time  ___Level II Undergraduate (i.e. B.A., B.ED., LLB) M        D        Y
___Level III Graduate or Professional (i.e. M.D.,M.A.)   
___Level IV - Doctoral (i.e. PhD's)
Program 

 Institution   Location                        


# courses

# credits

Length of Program



Year of Study

Academic Period for this Application   

     ____/____/_____     to       ____/____/_____    
M    D     Y                        M     D    Y
 
High School Graduate?  YES:_____  NO:_____
  
Last Year Attended High School:____________________
Most Recent Full Time Post Secondary Education

Institution                               Program

 dAtes attended



 fROM        to

 Funded Through
 ____          ____
 iNAC OR GRPSEO
         
Self funded		  Program Completed


 ____      ____
 YES        no
 
I declare that all of the above information is complete, true and accurate and I agree to inform the Grand River Post Secondary Education Office of any changes which may affect my eligibility for allowance. I also declare that I have read,  understood and agree to comply with all definitions, rules and guidelines listed on the Rules, Guidelines and Definitions Page.

Signature:__________________________________________
 Date:____________________________________________


For Office Use Only
Priority_____ Study Code_____ Qualification Code_____ Institution Code______
Original Application  ___   Signed ___  Dated ___ Cost Fiscal Year 
20____ / 20____		 Fiscal Year
20____ /20____
Photocopy of Status Card (BOTH SIDES)
Consent to request/release information
                          Signed ___  Dated ___ Witnessed ___
Tuition    
Bank Deposit Info (void cheque) E-Mail Address
Tuition Fee Statement Marks/Progress Rpt Books    
Detailed Tuition Breakdown Official Transcript Education Allowance _______Months@_________    
Residence Fee Statement Verification of Registration Other    
Letter of Acceptance Education Plan Total Cost    
Secondary School Transcript Letter of Permission Student Months    

Counsellor:
Recommended ____  Not Recommended ____ Approved ____   
 Funding dependent on receipt of required documents  ____

Funding Dependant____ Funds on Hold ____ OVP to be cleared____		 Rejected ____
Comments Comments
_________________________________________________ __________________________________________________
_________________________________________________ __________________________________________________
_________________________________________________ __________________________________________________
Counsellor Signature

Date

 Director/Designate Date
______________________         __________________

Return a signed original to G.R.P.S.E.O. 

____________________________            _________________  

AP1001A08

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