Participant Application Form

Required information is indicated by *.

Name:	*
University/Program/Year:	*
Student Identification #:	*
Loran Scholar?	*	Yes No
Address while at University
Street:	*
City / Province / Postal Code:	*
Home Address (if different from above)
Street:
City / Province / Postal Code:
Citizenship:	*
Do you have a valid passport?	*	Yes No
Personal Email Address:	*
University Email Address:	*
Cell Phone Number:	*
Home Phone Number:	*
Date of Birth (DD/MM/YY):	*
Briefly tell us why you wish to participate in the Intercordia Canada Program: *

What skills, experience and interests will you bring to the program: *

Describe any cross cultural experiences you have had and/or experiences living/working with marginalized or vulnerable people: *

How do you think the Intercordia Program will enhance your life and/or career: *

Declaration: I declare that the information given on this form is to the best of my knowledge true and complete. I agree to any Criminal Records Bureau or Police checks which may be required as part of Intercordia procedures. I agree that the information provided in this application form may be processed by Intercordia in relation to my application in order to assist in the decision making process. I further expressly agree that, should it be necessary to validate any of the information provided therein, Intercordia may release the information for verification purposes. If I am successful in my application, it is agreed that any information provided will be retained by Intercordia in a secure and confidential file, and the contents used only for necessary business purposes, subject to my express consent for disclosure where necessary.
Signature (type name):	*
Date:	*
Please enter the word you see in the image	*