online studying institution

1. Room 114, Wakpa Tower
3737 Wascana Parkway
Regina, SK Canada S4S 0A2
Phone: 306-585-4585 Fax: 306-585-4971
esl@uregina.ca www.uregina.ca/esl
To apply for the Academic ESL Program, please complete this form electronically and make sure you do the following:
 Pay the non-refundable application fee ($100 CAD), if you have NOT already applied to a credit program at the U of R.
 Pay the non-refundable tuition deposit ($500 CAD per semester), deducted from your total tuition amount.
 If you are a permanent resident in Canada, submit a copy of your Permanent Resident Card.
 If you are a Canadian citizen, submit a copy of your passport.
 If you are applying through an agent, or on behalf of someone else (e.g. a friend or relative), then complete and submit the
Declaration of Third Party Authorization form with this application form, which is available on our website: www.uregina.ca/esl
 If you have taken the IELTS Academic Test within the last 2 years, include a copy of the score report. If you have an overall

score of 6.0 with no band lower than 5.0, you are eligible to gain direct entry to Advanced EAP.
If you have an overall score of 5.5 with no band lower than 5.0, you are eligible for direct entry to ESL 040 High Intermediate.
Send the completed form, including a scanned copy or photocopy of your passport, to our address (indicated above).
PERSONAL INFORMATION
LAST/FAMILY NAME:
FIRST NAME:
GENDER: Male:  Female: 
U OF R STUDENT ID (If applicable): ID #:
DATE OF BIRTH: _____ Day/ _____ Month/ _____ Year
VALID PASSPORT #:
STATUS: International student:  Canadian Citizen:  Permanent resident: 
Country of Citizenship: __________________________________________________
SPONSORSHIP INFORMATION (If
you are a financially sponsored
student, check off which program
applies to you; if it is not listed,
indicate it beside “Other” ):
Science without Borders/Canadian Bureau for International Education (CBIE): 
Saudi Arabian Cultural Bureau (SACB): 
Libyan-North American Scholarship Program:  Kuwait Cultural Bureau: 
Other: _______________________________________________________________
EMAIL ADDRESS:
PERMANENT ADDRESS (Inside or
outside Canada; this address will
appear on your Letter of
Acceptance):
Street: ________________________________________________________________
City:__________________________ Province/State: ___________________________
Country: ________________________________ Postal/Zip Code: ________________
MAILING ADDRESS (If different
from address above):
Same as “PERMANENT ADDRESS” above: 
Street: ________________________________________________________________
City: _________________________ Province/State: ___________________________
Country: _________________________________ Postal/Zip Code: _______________
PHONE # (Local or international):
EMERGENCY CONTACT
INFORMATION:
Name: ________________________________________________________________
Relationship to you (e.g. father, mother, etc.): ________________________________
Email: ________________________________________________________________
Phone #: ______________________________________________________________
ACADEMIC BACKGROUND : Have you attended an educational institution in the past year? Yes:  No: 
If you checked off “Yes”, then please indicate the educational institution below:
_____________________________________________________________________
PERMIT INFORMATION: Do you already have a study/work/visitor’s permit issued by the Government of
Canada? Yes:  No: 
CANADIAN VISA INFORMATION: Have you applied for your Canadian visa yet? Yes:  No: 
Have you obtained your Canadian visa yet? Yes:  No: 
HOW DID YOU FIND OUT
ABOUT US?
Facebook: Friend/family member: Website: Agent: 
Other: _____________________________________________________________
V.11292017Save Reset Form Print Form

2. AGENT INFORMATION
NAME OF AGENT:
NAME OF AGENCY:
FUTURE PLANS
Are you planning to study at the U of R after you successfully complete the ESL Program? Yes:  No: 
Have you already applied to the U of R? Yes:  No: 
If you answered “Yes” to any of these questions:
 Check which program you are interested in:
 Indicate which faculty you are interested in:
Undergrad:  Grad: 
Faculty: _______________
ACADEMIC PROGRAM SEMESTER DATES AND TUITION
SEMESTER* TUITION (CAD)*
(International, including sponsored, students)
TUITION (CAD)*
(Canadian citizens / permanent residents)
$4170 $3272
FALL 2019 (Sep 3 - Nov 29)
(* Semester dates and tuition fees are subject to change without notice.)
PAYMENT OPTIONS
METHOD OF PAYMENT: Visa:  American Express:  MasterCard:  Wire Transfer: Bank Draft:  Other: 
IF YOU PAY WITH
CREDIT CARD:
Credit card #:
Card holder name:
Security code (3 digit # on back of card): __ __ __
Date of expiry (month/year): /
Signature: _________________________________________ Date: _____________________
COST BREAKDOWN: Would you like your Letter of Acceptance mailed by courier ($100 CAD*) fee? Yes:  No: 
(Acceptance Letters are mailed by regular post AND sent by email, unless you chose “Yes” above.)
i) If you indicated “Yes” to the above courier fee ($100 CAD*) = $ _________
ii) $100 CAD* application fee** = $ _________
iii) $500 CAD* non-refundable tuition deposit per semester = $ _________
Total amount you are paying = $
(* Fees are subject to change without notice.)
( ** If you have already applied to an undergraduate or graduate program at the U of R AND have paid
your $100 application fee, you do NOT need to pay the ESL application fee.)
I understand that admission to the ESL Program does not constitute admission to credit or degree
programs at the University of Regina. I assume full responsibility for my financial obligation, medical
coverage and other insurance plans.
Applicant signature: _____________________________________ Date: ___________________
 Your official Acceptance Letter will be sent to you once we receive the tuition deposit and application fee, if applicable.
 In order to be eligible for a Canadian study permit, which serves as a Canadian student visa during your stay, the
Government of Canada may require that you apply for a minimum of 6 months (or 2 semesters) in the ESL Program. Please
consult a Canadian visa office in your country to confirm the minimum length of time you are required to study in Canada.
Students with conditional admission, pending English proficiency, to an undergraduate or graduate program already meet the
minimum program length, and therefore should apply for only one semester.
 For more information about our Policies and Rules regarding fees, visit our website: www.uregina.ca/esl
 If you have any questions or concerns, please call 306.585.4585, or email esl@uregina.ca
Check off the semester(s) you are applying for:
Fall 2019Spr/Sum 2019
$4220 $3310
$4220 $3310
Winter 2020
SPRING/SUMMER 2019 (May 1 - July 26)
WINTER 2020 (Jan 2 - Mar 27)