FOR ACADEMIC AND ATHLETIC EXCELLENCE !

2010-2011 Bursary Application Form

Name : ____________________________ Sport : ___________________________

Under which category of the 2010-2011 scholarship program are you applying?

ENTRANCE BURSARY FOR QUEBECERS)

ENTRANCE BURSARY FOR CANADIAN (NON QUEBECERS)

PROCEDURE

1. Obtain a scholarship application form from the athletics department at a Quebec university or from the Foundation office.

2. Read the information on the Foundation and its bursary program (pamphlet, objectives, eligibility criteria).

3. Complete the bursary application form and send it, along with a copy of your transcripts (college and highschool) to the following address :

Quebec Foundation for Athletic Excellence

a/s Pierre Dubé, Bursary Committee

4545, Pierre-De Coubertin Avenue

P.O. Box 1000, Station M

Montreal (Quebec)

H1V 3R2

e-mail: faeq@videotron.ca

4. Deadline for sending an application for all entrance bursary is February 12, 2010.

GENERAL INFORMATION

Last name: ________________________ First name: ______________________

Sport: _____________________________

Sex : Female Male

PRESENT ADDRESS PERMANENT ADDRESS (Parents)

____________________________________ __________________________________

(No, Street, Apt.) (No, Street, Apt.)

____________________________________ __________________________________

(City, Province) (City, Province)

___________________(___)____________ ____________________(___)_________

(Postal Code) (Telephone) (Postal Code) ( Telephone)

____________________________________ __________________________________

(Date of birth) (Social Insurance Number)

___________________________________________

E-Mail

INFORMATIONS ON THE BURSARY DEMAND

AND ON FINANCIAL SUPPORT

Are you identified by your provincial federation as an athlete of one of these categories ?

Hopeful Elite Excellence

Do you have a Senior, or a development card from Sport Canada?

Yes No

If yes, which ? Senior _____ Development ___

Do you receive financial support from other sources ?

Yes No

If yes, which ? __________________________________________________

Source _______________ Amount ______________________

_______________ ______________________

_______________ ______________________

ATHLETIC CAREER INFORMATION

YEAR	TEAM OR CLUB	COACH
2007-2008
2008-2009
2009-2010
2010-2011

BEST ATHLETIC PERFORMANCES

DATE

NAME OF COMPETITION

PLACE

RANK

PERFORMANCE

SPORTS AWARDS RECEIVED

(not mentioned previously)

DATE

NATURE

2010-2011 ATHLETIC OBJECTIVES

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___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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ACADEMIC INFORMATION

YEAR	INSTITUTION	MAJOR	DIPLOMA
2007-2008
2008-2009
2009-2010
2010-2011

Will you be a full-time student in September 2010 ?

Yes No

If not, explain why ? _________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Did you receive honour or distinctions for your academic performances?

Yes No

DATE

HONOURS

N. B. : Enclose a copy of your College or Highschool transcript -MANDATORY

SPACE RESERVED FOR THE SELECTION COMMITTEE

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