Value: Full tuition for up to four consecutive years Deadline: January 31 The following information will be used in determining eligibility for the Presidential Scholarship. Please answer the questions and complete the form fully. Upon completion, please hit submit at the bottom of the page. Name of Applicant First Name: Middle Name: Last Name: Mailing Address Address Line 1 Address Line 2 City: Province: Postal Code: Phone: E-mail: Community Leadership (please check) The student I have nominated has participated in at least one of the following areas during grade 11 and/or the first semester of grade 12. Check all that apply and provide details. Music Music Music desc Athletics Athletics Athletics desc Student Leadership Student Leadership Student Leadership desc High School and/or Community Service High School and/or Community Service community desc Academic Requirements Minimum 85% overall average based on Ambrose admission requirements—average on ENG 30-1, 3 List A or B classes, 1 List A, B, C or D class and any program specific requirements. Acknowledgement I certify that the information provided in this reference form is true and complete in all aspects. I understand that Ambrose University will use the above information in selection for the Presidential Scholarship and will be in contact with the student directly. Acknowledgement Yes Teacher or Principal Name Teacher or Principal Email School Name School Phone Number School Address Line 1 School Address Line 2 City/Town Province/State Postal Code/Zip Code Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 The personal information collected on or in conjunction with this form is collected under the authority of the Personal Information Protection Act (PIPA), the Statistics Act (Canada) and the Income Tax Act (Canada). It is required to determine your eligibility for admission and will be used to contact you regarding programs and services. It will form part of your record as an applicant, student, and alumnus and may be disclosed to academic and administrative units. Specific data elements may be disclosed to the Federal and Provincial Governments to meet reporting requirements. Since the Jason Lang Scholarship is a Student Aid Alberta Scholarship, this information will be given to Student Aid Alberta. If you have any questions about the collection, use or disclosure of this information, call the Student Aid Alberta Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Student Aid Alberta, PO Box 28000 Station Main, Edmonton, AB T5J 4R4. All other information is considered confidential and will be used and disclosed in accordance with privacy legislation. For more information regarding the collection or use of this information, please contact the Privacy Compliance Officer (403-410-2000 or e-mail email@example.com).