Preliminary Application formINSTRUCTIONS - Fill out the form. - Attach a cheque or a Money Order for $75 (opening file fee non refundable) payable to AFS Interculture Canada. - Make sure your parents sign the form. - Send it to the following address: AFS Interculture Canada 1425 René-Lévesque blvd. West, Suite 1100 Montreal (Québec) H3G 1T7

First name and surname

Mother's name or guardian

Father's name or guardian

Address No.

School's name

Telephone (home) Mobile

E-mail

E-mail

E-mail

City

Birth Date

Postal Code Postal Box

Province

I'm interested in the following destinations

Gender

Year of departure Summer or Winter departure Type of program

How did you hear about AFS Interculture Canada?

If you can, give details (for example, if you indicated "Internet", you may add "google search engine", or if you marked "local newspaper", write the name of the paper and the publication date, if you remember it).

I certify that the information submitted on this form is exact.

I encourage my child to pursue her/his application with AFS.

I am interested in obtaining information about hosting an AFS student.

Date

Date

Candidate's signature

Parent's or guardian's signature

Month Day Year