C
N
I
P
_ __
Location of study (Prince Albert, Regina, Saskatoon, Ile-a-la-Crosse, La Ronge, Yorkton):
__
Current BSN Year OR Year Entered PDBSN:
1. Personal Information:
Name
Permanent address
City Province
Permanent phone number
Current address
City
Current phone numbers (Home)
_Province
Student number
Postal Code
Postal Code
(Cell)
U of S e-mail
Male/female _
Name of emergency contact person
NSID
Date of birth (M/D/Y)
Address
City
Phone number
Province Postal Code
Relationship
Describe any physical/medical conditions that require special consideration

2. International Experience: If you have spent time in countries other than Canada, please indicate when and where.
Traveled:
Studied:
Worked:
3. Languages: Please list the languages (other than English) you speak and indicate your level of proficiency
(beginner, intermediate, advanced):
4. References:
List two references below, one professional and one personal.

Name
Phone #
Relationship to you
Email

Name
Phone #
Relationship to you
Email
Please direct your two references to our website where they will find the Reference Form ( they must send their recommendation directly to us and NOT through you to qualify) . They should send their document once signed by mail, email or fax to:
Lynn Jansen, Associate Dean,
Southern Saskatchewan Campus & International Student Affairs
College of Nursing, University of Saskatchewan c/o Regina Campus
100 - 4400 4th
Avenue Regina, SK
S4T OH8
By email send c/o elaine.maksymiw@usask.ca
Fax: (306) 337-3804 – Attention: Elaine Maksymiw

5. Letter of Application:
Address the following in a typed, double-spaced, two page letter of interest and submit with your application form to the address above in #4 (Please include a recent photo - any size, b&w or color) :

Why do you want to have an international practicum experience?

What particular skills, background, travel experience do you have that will enhance this experience and/or make you a good candidate?

What are the benefits of this experience for you personally, professionally and academically?

How are you prepared to cover expenses associated with this practicum?
6. Declaration
I hereby certify that my application is correct and complete. I understand that it is my responsibility to be aware of the academic and financial obligations associated with participating in this program.
Signature Date