SWORN STATEMENT

PETITIONER: ____________________________________

Student ID: ____________________________
Last Name: ____________________________

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

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