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Application Form

Online Executive MBA Program
The personal information collected on this form and any other personal information collected and maintained as part of your student record will be used for the purpose of admission, registration, issuing income tax receipts, scholarships and awards, convocating, for sending educational material and information, and for university research and planning. Certain personal information will also be disclosed to Statistics Canada, as required by the Statistics Act (Canada), and Alberta Advanced Education to meet reporting requirements, and by agreement to the Students’ Association and Alumni Relations for the purpose of membership, fee collection and contacting students. This information is collected under the authority of the Alberta Post-secondary Learning Act that mandates the programs and services offered by Athabasca University and section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. It will be protected by the Alberta Freedom of Information and Protection of Privacy Act. If you have any questions about the collection and use of this information, contact the Coordinator, Registry Services, Athabasca University, 1 University Drive, Athabasca, Alberta, Canada T9S 3A3 Telephone: (780) 675-6111 Fax: (780) 675-6174.

Applicant Information
Please print legibly

Mr.

Ms.

Dr.

Male

Female

Legal Name
LAST FIRST MIDDLE

Former Surname (if applicable)

Preferred First Name

Home Address
NUMBER STREET

CITY

PROVINCE/STATE

POSTAL CODE/ZIP

COUNTRY

Home Telephone Fax Social Insurance No.

Business Telephone E-mail Birthdate
DAY MONTH YEAR

Are you a person with a disability? Citizenship: Canadian

Yes

No

If yes, specify (optional) Non-Canadian temporarily residing in Canada (attach Study Permit)

Non-Canadian, permanent resident

If non-Canadian, please state citizenship: Please indicate the first language you learned and still understand: English French Other:

If you wish to declare that you are an Aboriginal person, please specify: Status Indian/First Nations Non-status Indian/First Nations Metis Inuit

Alberta Advanced Education is collecting this personal information pursuant to section 33(c) of the FOIP Act as the information relates directly to and is necessary to meet its mandate and responsibilities to measure system effectiveness and develop policies, programs and services to improve Aboriginal learner success in addition to other legislation applicable to the educational institution. For further information or if you have questions regarding the collection activity, please contact the office of the Director, Aboriginal Policy, Policy Sector, Information and Strategic Services Division, Advanced Education, 10155 - 102 Street, Edmonton, AB, T5J 4L5 (780) 427-8501.

all post-secondary education or highest level of education completed: Academic Institution Location Major Start and End Dates by Month/Year Highest Degree. This service can take from six to ten weeks. please specify: UNIVERSITY PROGRAM Yes Yes No No If “Yes. . and we recommend you contact IQAS to begin the process before sending in your application form.” AU Student ID # List in order. please specify: CGA-Canada CMA Canada Yes No Other: Department of National Defence Please help us measure our marketing strategy: How did you find out about the program that you selected? Word-of-Mouth: News Media (ads) Alumnus Web Search Yes Current Student Employer Other: Co-worker Other Professional Association No Did you attend an information session? If yes. you can change at any time) Are you applying under a special partnership agreement? If yes.Program Information MBA program starting in Fall Winter Spring Energy Project Management Do you plan to pursue specialized electives? If so. including those for professional designations have been ordered are on file at Athabasca University are on file at the Centre for Innovative Management Important note for international degree holders Transcripts from institutions outside of Canada and the United States must be evaluated by the International Qualifications Assessment Service (IQAS). indicate*: (*for estimating future class sizes only. IQAS must send their assessment directly to Athabasca University. See inside back cover for IQAS contact information. Diploma or Professional Designation Completed GPA All transcripts. beginning with the most recent. in which city? Academic Background Have you ever applied for a course at Athabasca University? Are you currently enrolled in another university program? If yes.

Insurance Government. Signature of Applicant Date Application Fee $200.499 employees CEO or Owner Vice President Current Salary $ Senior Manager/Director Manager Other 500 .50% 76 .99 employees 100 . I agree that Athabasca University retains the right to nullify my application if the information provided is false or incomplete. Oil and Gas Engineering Finance. Forestry. Culture Construction. is that support essential to your participation in the program? Percentage of financial support: < 25% 25 . Industrial Development.75% Hospitality 50 .99% 100% Acknowledgement I agree to abide by the rules and regulations and fee requirements of Athabasca University as outlined in the current Athabasca University calendar.10. Real Estate Consulting Education Sector Private Public Energy.00 CAD Application Fee enclosed (non-refundable) Bankdraft Cheque Visa MC Amex CARD NUMBER EXPIRY NAME AS IT APPEARS ON CREDIT CARD SIGNATURE OF CARDHOLDER DATE .Current Employment Information Organization Name Organization Address NUMBER STREET CITY PROVINCE/STATE POSTAL CODE/ZIP COUNTRY Current Position Responsibility Level Organization Size < 50 employees Industry Agriculture. Entertainment.000 employees > 10.000 Other Retail and Wholesale Trade Transportation and Logistics Utilities and Telecommunications Information Technology Manufacturing Military and Policing Not-for-Profit and Social Services Will you receive tuition support from your employer? If yes. Public Service Health Care Not-for-Profit Yes No Yes No 51 .999 employees 1000 . as they may be amended from time to time. I understand that all documents received in support of this application become the property of the University. Renewable Resources Arts. Mining. I certify that I am not under suspension or dismissal from another institution for reasons of academic misconduct. I certify that the information provided in this application is true and complete in all respects and that no relevant information has been withheld.

Name of Referee LAST FIRST Title/Position Work Address NUMBER STREET Company CITY PROVINCE/STATE POSTAL CODE/ZIP COUNTRY Telephone Fax Number E-mail Evaluation Questions Attach your letter of reference to this form and return it to the applicant or mail to the Centre for Innovative Management. References should be of a professional nature and comment on the individual’s proven depth and breadth of management skills and ability to successfully undertake graduate level studies. 301 . Strongly recommend Recommend Recommend with reservations Do not recommend that this applicant be admitted to Athabasca University’s Graduate Management Programs. How would you describe the applicant’s research. The applicant may. Declaration I. analytical. view your letter. How would you describe the applicant’s academic (scholarly) strengths and weaknesses? 4. Albert. and writing skills? 3. Signature of Referee Date In accordance with the FOIP Act. 1. St. whom you should know well enough to evaluate fairly and accurately. . We would appreciate your assistance in our admissions process by providing us with your candid assessment of the applicant. Please include any additional comments you wish to make concerning the applicant’s suitability for study at the graduate level. upon request. communication. the information contained in letters of reference is NOT considered confidential.22 Sir Winston Churchill Avenue. Please respond to the following questions and add any observations or comments that you think are relevant to this applicant’s goal to obtain a graduate business degree. How long have you known the applicant and in what capacity? 2.Athabasca University Centre for Innovative Management Executive MBA Program Academic Reference for Admission (Referee Form) Name of Applicant LAST FIRST Title/Position Company The above-named person has applied for entry into one of Athabasca University’s graduate management programs. AB T8N 1B4.

St. Albert. Describe the applicant’s strengths and weaknesses in relation to: • managerial experiences and skills • intellectual capabilities (e. In your opinion. the information contained in letters of reference is NOT considered confidential. whom you should know well enough to evaluate fairly and accurately.22 Sir Winston Churchill Avenue. analytical skills. Declaration I. References should be of a professional nature and comment on the individual’s proven depth and breadth of management skills and ability to successfully undertake graduate level studies. The applicant may. Name of Referee LAST FIRST Title/Position Work Address NUMBER STREET Company CITY PROVINCE/STATE POSTAL CODE/ZIP COUNTRY Telephone Fax Number E-mail Evaluation Questions Attach your letter of reference to this form and return it to the applicant or mail to the Centre for Innovative Management.Athabasca University Centre for Innovative Management Executive MBA Program Business Reference for Admission (Referee Form) Name of Applicant LAST FIRST Title/Position Company The above-named person has applied for entry into one of Athabasca University’s graduate management programs. Signature of Referee Date In accordance with the FOIP Act. how would this program improve the applicant’s career or professional opportunities? Please include any additional comments you wish to make concerning the applicant’s suitability for study at the graduate level. 3. Please respond to the following questions and add any observations or comments that you think are relevant to this applicant’s goal to obtain a graduate business degree. conceptualization and problem solving) • oral and written communication skills 4. We would appreciate your assistance in our admissions process by providing us with your candid assessment of the applicant. . 301 . 1. view your letter.g. original and critical thinking. How long have you known the applicant and in what capacity? 2.. upon request. Strongly recommend Recommend Recommend with reservations Do not recommend that this applicant be admitted to Athabasca University’s Graduate Management Programs. AB T8N 1B4.

analytical skills.g. .. 301 . 1. how would this program improve the applicant’s career or professional opportunities? Please include any additional comments you wish to make concerning the applicant’s suitability for study at the graduate level. view your letter. Name of Referee LAST FIRST Title/Position Work Address NUMBER STREET Company CITY PROVINCE/STATE POSTAL CODE/ZIP COUNTRY Telephone Fax Number E-mail Evaluation Questions Attach your letter of reference to this form and return it to the applicant or mail to the Centre for Innovative Management. Albert. conceptualization and problem solving) • oral and written communication skills 4. whom you should know well enough to evaluate fairly and accurately. Signature of Referee Date In accordance with the FOIP Act. 3. upon request. Please respond to the following questions and add any observations or comments that you think are relevant to this applicant’s goal to obtain a graduate business degree. In your opinion. AB T8N 1B4. Strongly recommend Recommend Recommend with reservations Do not recommend that this applicant be admitted to Athabasca University’s Graduate Management Programs. The applicant may. Describe the applicant’s strengths and weaknesses in relation to: • managerial experiences and skills • intellectual capabilities (e. the information contained in letters of reference is NOT considered confidential. St.22 Sir Winston Churchill Avenue. original and critical thinking. How long have you known the applicant and in what capacity? 2. We would appreciate your assistance in our admissions process by providing us with your candid assessment of the applicant. References should be of a professional nature and comment on the individual’s proven depth and breadth of management skills and ability to successfully undertake graduate level studies.Athabasca University Centre for Innovative Management Executive MBA Program Business Reference for Admission (Referee Form) Name of Applicant LAST FIRST Title/Position Company The above-named person has applied for entry into one of Athabasca University’s graduate management programs. Declaration I.

Strongly recommend Recommend Recommend with reservations Do not recommend that this applicant be admitted to Athabasca University’s Graduate Management Programs. Declaration I. conceptualization and problem solving) • oral and written communication skills 4. 3. 301 . analytical skills. References should be of a professional nature and comment on the individual’s proven depth and breadth of management skills and ability to successfully undertake graduate level studies. The applicant may. view your letter. how would this program improve the applicant’s career or professional opportunities? Please include any additional comments you wish to make concerning the applicant’s suitability for study at the graduate level. St. In your opinion. AB T8N 1B4.Athabasca University Centre for Innovative Management Executive MBA Program Business Reference for Admission (Referee Form) Name of Applicant LAST FIRST Title/Position Company The above-named person has applied for entry into one of Athabasca University’s graduate management programs. the information contained in letters of reference is NOT considered confidential. whom you should know well enough to evaluate fairly and accurately. original and critical thinking. Name of Referee LAST FIRST Title/Position Work Address NUMBER STREET Company CITY PROVINCE/STATE POSTAL CODE/ZIP COUNTRY Telephone Fax Number E-mail Evaluation Questions Attach your letter of reference to this form and return it to the applicant or mail to the Centre for Innovative Management.g. Please respond to the following questions and add any observations or comments that you think are relevant to this applicant’s goal to obtain a graduate business degree.. . We would appreciate your assistance in our admissions process by providing us with your candid assessment of the applicant.22 Sir Winston Churchill Avenue. Describe the applicant’s strengths and weaknesses in relation to: • managerial experiences and skills • intellectual capabilities (e. Signature of Referee Date In accordance with the FOIP Act. 1. How long have you known the applicant and in what capacity? 2. upon request. Albert.