Online Survey | Built with Qualtrics Experience Management™

First name:

Last name:

Laurier ID:

Laurier email:

Phone number:

Local address:

Street Address Line 1

Street Address Line 2

City

Province/State/County

Country

Postal Code/Zip Code

Program:

Year of study:

Name of postsecondary institution you have attended:

Discipline/major:

List any scholastic distinctions or honours you have received:

List your contributions to the History program (e.g., particular activities, in class participation and presentations, history student and club activities, membership of student and faculty councils, research work):

Describe the reason(s) for your interest in historical studies, and how this interest relates to your professional and academic goals:

Describe how your plans for your fourth year, and this scholarship, will help you realize your professional and academic goals:

Acknowledgement statement:

By checking this box, I am providing my electronic signature whereby I accept that my academic record may be assessed and taken into consideration prior to any decisions being made.

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