Program in Insurance medecine `and medicolegal evaluation`

Admission

Admission application for Graduate Studies

If you have any questions about this form you can reach Eva Medalsy, Eddy Martin, or Dr. Claude Mercier at the following e-mails:

Eva Medalsy: eva.medalsy@umontreal.ca

Eddy Martin: emartin@cmaisonneuve.qc.ca

Dr. Claude Mercier: claude.mercier.1@umontreal.ca

IMPORTANT: U of M will only accept original documents or true copies certified by an authorized person.

a copy of your faculty marks or certified copy of your MD diploma or PhD/DSc diploma

a birth certificate and a Canadian Permanent Residency (PR) card (both sides) with IMM5292 or IMM1000 supporting document and a Canadian citizenship card (both sides)_Certified copies

a 21.40 $ Application fee, to be paid online on the "Université de Montréal" official application form, by Credit Card only, Visa or MasterCard, for the « Introduction to the Field of Medico-Legal Expertise »

Mandatory documents must be uploaded in your student center

Identification Family name: First name: Family name (if different from birth name - see the general instructions):

Gender female Male

Date of birth (day / month / year): First language or mother tongue: Language spoken the most at home: Social insurance number (optional):

Place of Birth City: Province or state: Country:

Father's family name: Father\'s first name : Mother's family name (at birth): Mother's First name:

Address Address number: Street: Apartment : Rural mailroute, PO Box and Postal Station or general delivery: City: Province or state: Country: Phone Number 999-999-9999(Home): Phone Number 999-999-9999(Office): Extension: Postal Code: e-mail: Fax 999-999-9999:

Citizenship Status

Citizenship Status Canadian Citizen Permanent Resident (Landed immigrant) Student Visa Refugee

Country: If you are a landed immigrant, please indicate in which province you stayed upon your arrival.:

Current Studies Name Address of Educational Institution: Year Attended (Start) MM/YYYY: Year Attended (End) MM/YYYY : Degree Expected: Expected Date of Graduation: DD/MM/YYYY :

Previous Education

Name Address of Educational Institution	Year Attended (from ... to): MM/YYYY-MM/YYYY	Degree Expected	Expected Date of Graduation: DD/MM/YYYY

Québec Code permanent Québec Code permanent:

Current Employment (candidate coming from the labour market) Specialty : Employer: Address:

Entry in the record of the Registry of Civil Status Entry in the record of the Registry of Civil Status:

Employment during your studies Full time Part time Duty: Employer:

Scholarship application Funding agency: yes no Have you already received a scholarship for your upcoming studies

Funding agency: yes no Have you submitted a scholarship application

Language knowledgeE=EXCELLENT; G=GOOD; P=POOR

References

Reference 1 Family name: First Name: Title / Name of Educational Institution / organization / address :

Reference 2 Family name: First Name: Title / Name of Educational Institution / organization / address :

Reference 3 Family name: First Name: Title / Name of Educational Institution / organization / address :

Previous applications no yes Did you apply to the Université de Montréal during the past twelve months

Year: no yes Did you apply in the past for Graduate Studies at Université de Montréal

no yes Are you currently registered at the Université de Montréal or have you been registered in the past in Undergraduate studies

no yes Are you currently registered at the Université de Montréal or have you been registered in the past in Graduate studies

Year of your last registration: programmefinderniereinscription:

Program choice programme

Program Number: Name of Program:

Term of Entry Year: Summer Winter Fall

Status Full time Half time Part time

Authorization and declaration

I authorize the Ministry of Education and the educational institutions where I have studied the disclosure of my academic achievements to the Université de Montréal. I understand that the Université de Montréal will provide the Ministry of Education the information needed to create or validate my Permanent Code. I authorize the Université de Montréal to transmit to the Conference of Rectors and Principals of Québec Universities (CREPUQ) information for the purpose of admissions operations and the production of statistics. I authorize the Université de Montréal to give information requested by summons on me. If applicable, I authorize the Ministère des Relations avec les citoyens et de l’immigration to transfer to the Université de Montréal, on my behalf, the confirmation of the deliverance of the Quebec certificate of acceptance. I certify that I have read the information provided with the application form and that all statements are correct and complete. I acknowledge that any false declaration or omission of giving relevant information in a document related to my admission or my registration may result in revoking my admission or registration to the University.

Date:

T:Insurance medecine and medicolegal evaluation | A: Faculté de médecine C.P. 6128, succursale Centre-ville Montréal, Québec, Canada H3C-3J7 |

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Program in Insurance medecine and medicolegal evaluation

Admission

Admission application for Graduate Studies

Program in Insurance medecine `and medicolegal evaluation`