HAITIAN STUDENT SCHOLARSHIP
Terms and Eligibility Criteria:
The Haitian Student Scholarship is a four-year continuing award, available to a full-time student in a
degree program who has been impacted financially by the earthquake in Haiti. At that time the program
will be reviewed to determine if it should be continued for a further four-year period. The recipient must
meet Western admission requirements; be a Haitian citizen or landed immigrant who has been in
Canada for no longer than two years prior to the start of the study period; be admitted as a full-time
student at main campus in a degree program or graduate program; be impacted financially by the
earthquake in Haiti; and must maintain full-time status and satisfactory academic standing each year.
Preference will be given to a student entering Year 1. Upper-year students may apply for the tuitiononly component of this scholarship. Students with demonstrated financial need must submit an
application to Student Financial Services, Rm. 1120, Western Student Services Building, by May 30 of the
year admitted. Recipients can receive this scholarship up to four years if they remain registered as a fulltime student in good standing at main campus.
Value of Award:
Recipients in the following programs will receive full tuition, including ancillary and other compulsory
fees, as well as up to $10,000 towards the first-year residence and meal plan costs. After first year, the
scholarship will cover full domestic or international tuition and ancillary fees only.
Eligible First Entry Programs:
Faculty of Arts and Humanities
Faculty of Engineering
Faculty of Information and Media Studies
Faculty of Health Sciences
Don Wright Faculty of Music
Faculty of Science
Faculty of Social Science (excluding flight fees for commercial aviation program)
Recipients in the following programs will have the lesser of full tuition and ancillary fees or $15,000
applied towards their tuition ($5,000 per term for graduate students).
Richard Ivey School of Business (HBA program)
All Graduate programs (awarded in addition to other graduate scholarships and awards)
Law
Medicine
Dentistry
Note: This is not an admission application. This application is used for scholarship consideration only. You must
also submit an admission application to be considered for the scholarship. For information on how to apply for
admission to the University of Western Ontario please visit: welcome.uwo.ca.
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HAITIAN STUDENT SCHOLARSHIP APPLICATION
2012- 2013
Application Deadline: May 30, 2012
Return to:
University of Western Ontario
Student Financial Services
Western Student Services Bldg, Rm 1120
London, ON
N6A 3K7
Fax: 519-661-2083
Contact:
Kristy Doyley
Student Financial Services Officer
Ph: 519-661-2111 x80256
Email: kmonagh@uwo.ca
Applicant Information
Last Name
First Name
Western Student ID
Date of Birth (dd/mm/yyyy)
Year Level (circle one)
Academic Career (check one)
Undergraduate
Graduate
Professional
Do you currently live in Canada?
Yes
No
Year:
Program/Faculty
1
2
3
4
Citizenship status (check one)
Haitian citizen
Permanent Resident (landed
Immigrant in Canada)
If you are currently living in Canada
when did you arrive in Canada?
Date:
*required to submit proof of
Telephone Number
(mm/yyyy)
citizenship – Permanent Resident
Card or valid passport
Email Address
*Note: You must attach appropriate documentation as proof of your citizenship status to this application. If you
are a Permanent Resident of Canada (landed immigrant) you must submit a copy of the front and back of your
Permanent Resident card. If you are a Haitian citizen you must submit a copy of your valid passport.
Family Information
Are your parents divorced/separated?
with?
Yes
No
If yes, which parent do you currently live
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Note: If your parents are divorced/separated please provide information for the parent that you currently or last
lived with (and their spouse if they have remarried).
Mother’s Name:
Father’s Name:
Spouse’s Name:
Mother: In what country does your
mother currently live and work?
Mother: What is your mother’s
occupation?
Father: In what country does your
father currently live and work?
Self Employed:
Yes
No
Father: What is your father’s
occupation?
Spouse: In what country does your
spouse currently live and work?
Self Employed:
Yes
No
Spouse: What is your spouse’s
occupation?
Self Employed:
Yes
No
If your parent(s)/spouse currently live in Canada, when did they arrive in Canada? (please provide date)
Mother:
Father:
(mm/yyyy)
Spouse:
(mm/yyyy)
(mm/yyyy)
Supplementary Statement (Please attach to this application form)
The Haitian Student Scholarship is to be awarded to a student who has been impacted financially by the
earthquake in Haiti. Please describe in 500 words how you and your family were impacted by the
earthquake.
Additional Information:
Please be aware that if we determine that you are eligible to be considered for this scholarship based on
the information provided on this form, you will be asked to submit supplementary documentation in
support of your application. If additional documentation is required you will be contacted via email to
request the documentation. Below is a list of documentation that may be requested at a later date:
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Copy of Canada Revenue Agency Notice of Assessment or equivalent federal income tax
document that has been notarized if living outside of Canada
Business Statements (if parents/spouse are self employed)
Copy of recent property tax assessment or equivalent documents that have been notarized if
living outside of Canada
Documents showing the value of any investments/assets owned
Affidavit confirming that your family’s financial situation has been represented accurately in the
application
Declaration:
1. The information provided on this application is complete and accurate and I require additional funds to pursue my studies at The University
of Western Ontario (herein, UWO).
2. I consent to the use of personal information provided on this application or accompanying documentation for the purpose of determining my
eligibility for financial assistance.
3. All information provided in connection with this application is subject to audit and verification by UWO. I consent to the disclosure of
information on this application to the Ministry of Training, Colleges and Universities and any other source when necessary for audit and
verification of the information provided. Documentation may be requested at a later date based on an audit.
4. If any information is found to be untrue, I agree to pay back any funds I have received as a result of this application.
5. The value of any bursary or award I receive will be applied to my student tuition account.
6. The decision on my application for financial assistance and the amount of funding awarded, if applicable, will be communicated to me via my
UWO email account.
7. Financial Aid Profile Privacy Notice and Declaration The information on this form is collected under the authority of the University of
Western Ontario Act, 1982, as amended, and is needed to process your application, and decide your eligibility for work study, bursaries or Need
Based Awards. The Office of the Registrar may disclose designated information to government funding agencies. In addition, the Office of the
Registrar may disclose to the award donor, who may use your information in publications associated with the bursary/award, and share with
the appropriate Faculty, Department(s), and School(s) the following student personal information: name, address, biographical data, faculty,
academic programs, and any other information that confirms eligibility for and receipt of a bursary or award. This information may also be
published in a document prepared for donors and potential donors that lists recipients of donor-funded scholarships, awards, and bursaries. If
you do not wish to be included in such a publication, please go to http://www.registrar.uwo.ca/FinancialServices for information on how to
opt-out of the publication. Your decision to opt-out will in no way affect your eligibility to receive future scholarships, bursaries, or need-based
awards. If you have any questions or concerns about the collection, uses, and disclosure of this information by the University, please contact
the Training and Security Team Leader, Office of the Registrar, Western Student Services Building Room 1140C, The University of Western
Ontario, London, ON, N6A 3K7, tel: 519-661-2111, extension 82680
I understand that if any information is found to be untrue or inaccurate, this application may be considered
cancelled and any money received as a result will have to be returned. If I receive additional financial resources
(eg. sponsorships, external awards/scholarships) after this application is signed, I will disclose the information to
the Student Financial Services office during the application process and if I am a successful recipient of this
scholarship. I will contact Kristy Doyley at kmonagh@uwo.ca if I need to provide new or revised information
related to this application.
Date
Applicant Signature
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