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LONDON GOODENOUGH ASSOCIATION OF CANADA
2015-2016 SCHOLARSHIP APPLICATION FORM
Please send all completed Applicant Materials comprised of: this Application Form, the Applicant Statement of
Purpose, a Thesis Statement (if applicable) and any relevant supporting material to the address below. In addition, applicants
must arrange for the applicable parties to send the required Supporting Materials which consist of original transcripts from
ALL post-secondary institutions attended (including CEGEPs, exchange study, etc.) and 3 confidential Letters of Reference
(normally from academic or professional referees with direct knowledge of your qualifications for your proposed course of study) to
the address below. Many common questions are answered on our scholarship FAQ, found on the LGAC website: lgac.ca.
Candidates must be full-time students enrolling in an accredited graduate program in London or undertaking thesis research in
London while enrolled elsewhere. Candidates must be Canadian citizens or permanent residents of Canada.
Scholarship winners are required to reside at Goodenough College for a full academic year, although up to two awards for a
minimum of six months residency to support thesis research will be considered. Scholarships will not be renewed. Note that while
scholarhip winners are guaranteed single room accommodation only, flats may be available, subject to availability. The deadline
for receipt of all Applicant Materials and all Supporting Materials is January 26, 2015.
Applicants who would self-define as francophone in accordance with the definition specified on page 3 of this
form are asked to tick the adjacent Box. The LGAC may designate a successful applicant to be the winner of an
LGAC/Molson Foundation Scholarship for Francophone Canadians.
Last Name
First Name
Citizenship
CURRENT ADDRESS
PERMANENT ADDRESS (if applicable)
Address
City
Country
Apt.
Prov/State
Apt.
City
Prov/State
Country
Postal Code
Telephone
Email
Address
Postal Code
Telephone
For statistical purposes only I learned of this award by...
My home prov./territory is...
PROPOSED COURSE OF STUDY OR RESEARCH IN LONDON
University / College / Institute
Have you applied yet?
Arrival date (mm/yyyy)
Department / Program
Have you been accepted?
Departure date (mm/yyyy)
Expected Degree
Completion Date
Research
Locations
(Archives/
Institutes)
THESIS OR RESEARCH TOPIC
If you have a known thesis topic, attach a description of up to 500 words.
Check here if enclosed.
APPLICANT STATEMENT OF PURPOSE (English ou en français)
In an essay of up to 750 words, describe your academic goals, your purpose for study in London, your broader personal and career objectives, and your potential contributions to the academic and extracurricular life of Goodenough
College. (You may include additional relevant information for which there was insufficient space on this Form)
Statement
Enclosed
ACADEMIC EXPERIENCE (Original transcripts are required to be sent from each applicable institution)
University / College / CEGEP
Department / Program
Degree
Years (mm/yy -mm/yy)
ACADEMIC AWARDS (List your top 3 or most recent awards here and attach additional information if required)
Award
University / Granting Agency
Amount ($CDN) Years (mm/yy - mm/yy)
EXTRACURRICULAR ACTIVITIES (Attach additional information if required)
EMPLOYMENT EXPERIENCE (Attach additional information if required)
Employer
Years (mm/yy - mm/yy)
Position
NAMES OF REFEREES (Confidential letters of reference--preferably academic--are required to be sent by the applicable referee)
Name
Address
Email
Telephone
SOURCES OF INCOME (List only awards or income applicable during your prospective period in London)
Awards/Fellowships/Salary/Stipends
Amount
FURTHER INSTRUCTIONS AND INFORMATION FOR LGAC SCHOLARSHIP APPLICANTS:
1. Confidential letters of recommendation must be sent in sealed envelopes with the referee's signature appearing
across the back flap.
2. Academic transcripts must be received in envelopes that have been sealed and endorsed by the issuing institution to
authenticate their official status. It is preferred, though not required, that transcripts be mailed directly to the London
Goodenough Association of Canada (LGAC) by the issuing institution.
3. All documents and any other supporting materials submitted to the LGAC in support of an application for a scholarship
become the property of the LGAC and will not be returned to the applicant.
4. For the purpose of the LGAC / Molson Foundation Scholarship for Francophone Canadians award designation,
'francophone' means "French is spoken in the home and the candidate studied primarily in the French language". Supporting
evidence may be requested by the LGAC.
5. Scholarship winners are required to report any other awards they receive. Additional awards may reduce the funding
level of an LGAC Scholarship.
6. Declaration: This personal information is being collected solely for the purposes of adjudication for an award from the
London Goodenough Association of Canada (LGAC). It may be shared with other educational or scholarship associations
for the purposes of adjudicating and administering the scholarship. Award winners' names, addresses and contact
information will be maintained by the LGAC in its alumni database for the purposes of advancing and developing the
interests of the London Goodenough Association of Canada. Your information will not be sold to or shared with a third
party, except for the specific purposes noted above. We manage your personal information in accordance with the
Personal Information Protection and Electronic Documents Act (Canada) ("PIPEDA") and other applicable laws. If you have
any questions about the collection of this information, contact the LGAC Privacy Officer at L.G.A.C., P.O. Box 5896,
Station A, Toronto, ON, M5W 1P3, or by Email at: [email protected].
7. Your signature on the Application Form and/or your electronic submission of this form confirms the following:
a.
I HAVE READ AND UNDERSTOOD THE INSTRUCTIONS ON THE APPLICATION FORM, INCLUDING THIS INFORMATION
SHEET, AND THAT ALL STATEMENTS MADE IN CONNECTION WITH THIS APPLICATION ARE TRUE AND COMPLETE.
b.
I AUTHORIZE THE LGAC, ITS BOARD OF DIRECTORS OR DESIGNATE TO VERIFY ANY INFORMATION, TRANSCRIPT, OR
REFERENCE LETTER PROVIDED AS PART OF THIS APPLICATION.
c.
I UNDERSTAND THAT MY APPLICATION WILL BE REJECTED IF I HAVE NOT DISCLOSED MY COMPLETE ACADEMIC
RECORD OR HAVE SUBMITTED FALSE INFORMATION IN SUPPORT OF THIS APPLICATION FOR A LGAC SCHOLARSHIP.
Print Form
Date
Signature
The deadline for receipt, at the address below, of all Applicant Materials and Supporting Materials for the 2014-2015
Scholarship Program is January 26, 2015. Transcripts must arrive sealed and reference letters must be sent in sealed envelopes
with the referee's signature across the flap. Only Applicant Materials (which includes this Application Form, Thesis Research
Description, Statement of Purpose), and not Supporting Materials may be sent by email to [email protected]. If necessary, unofficial
copies of Supporting Materials (but not Applicant Materials) may be faxed to (905) 492-1719, provided that the LGAC is also sent an
authenticated original. If sending by courier, please ensure they will deliver to a Post Office Box. Candidates will be notified of their
application results in late April 2015. For further information and our scholarship FAQ, visit the LGAC website lgac.ca.
THE LONDON GOODENOUGH ASSOCIATION OF CANADA
Evan Thomas, Chair
PO Box 5896, Station A
Toronto, ON M5W 1P3
CANADA
Registered Charity #891107146 RR0001