I hereby enroll for the Diploma or Course Title: _________________________________

_____________________________________________________________________________________

Or Certificate Courses: _____________________________________________________________

Full Time: _____ Part Time: _____ Correspondence ______ Self Learning: ________

Training to begin with the date of acceptance at Campus or Head Office: _______

I understand the registration fee is included in the total course fee and I promise to pay for the course of 
instruction the sum of $______________ or the course fee is paid by: ________________

Make cheque or money order (If applicable) payable to PBI.)

Enrollment Date: ________________________ Shift #1____ #2_____ #3_____

Name: Mr. __ Mrs. __Ms.___________________________ Signature: ______________________

Address: ____________________________________________________________________________

City: ______________ State or Province: _________________ PC: _______________

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Personal Details:

Your telephone number: Home_______________ Work_____________E-mail:__________________

Your prior PBI student number: __________________________

Canadian: ______ Landed Immigrant ____ Visa Student: ____

Your Date of Birth: Day_________ Month_________________ Year____________________

Education: Grade 9__10__11__12-- College 1__ 2__ 3__ 4__ University: __________

Title of current or prior job: ______________________________________________________

Supervisor Name: __________________________Company Name: ____________________________

Address: ___________________________________ City: ____________ Province: ___________

Postal Code: ______________ Tel.: ____________Fax:____________Email:_________________

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Starting Date: |End Date: |Extension Date: To:

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Approval Initials: |Diploma Date:|Certificate Date: |Average Mark:

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Tax Exempt Certificate Date: |Diploma Date: Remarks:______________________________

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