SWORN STATEMENT

PETITIONER:          

ADDRESS:          

CITY/PROVINCE:                 POSTAL CODE:                   HOME PHONE: (        )         WORK PHONE: (        )        

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