SWORN STATEMENT

PETITIONER: ____________________________________ ADDRESS: ______________________________________ CITY/PROVINCE: _________________________________ POSTAL CODE: __________________________________ HOME PHONE: (______)___________________________ 

WORK PHONE: (______)___________________________ 

Student ID: ____________________________ Last Name: ____________________________ Given Name: ___________________________

 Concordia University  

 Enrolment Services, FB 900  

 (Provincial Residency)  

 1455 Boulevard de Maisonneuve W.   Montréal, Québec  

 H3G 1M8

I, _________________________________________________ born on  Full name (given name, family name and married name if applicable)  

_____________________ in __________________________________ Day, Month, Year Place of birth (city/town, country)  

swear that from _____________________ to _____________________ ,   Day, Month, Year Day, Month, Year  

I did not pursue full-time credit studies at an educational institution in Québec.  

I am aware that by making this statement that I give Concordia University and  their agents the authority to confirm this statement to be true with the Ministère  de l’Éducation et de l’Enseignement supérieur (MEES).

I declare that the statement in this document is true, accurate and complete. I  understand that I am subject to the Canada Evidence Act by making this  declaration under oath. Any false declaration carries legal recourse and will  result in the non-Québec resident tuition fees being charged back to my  

student account.

__________Initials  

Witnessed in __________________________________ on  

 City/town, country

DATE: _________________________________  

_______________________________________ ________________________________________ PETITIONER’S SIGNATURE COMMISSIONER OF OATHS

Enrolment Services  Concordia University  

 April 2019