Declaration, commitments and authorizations

This form must be signed to complete an online application for a Qubec Acceptance Certificate (CAQ) for studies.
Stengel, Noelle

No. of the CAQ application: 207216

I declare that the information contained in my online application for a CAQ for studies is complete and accurate.
I understand that the Ministre de l'Immigration et des Communauts culturelles may:
confirm, or have a third party confirm, the accuracy of information provided, and that I am breaking the law and am liable to a
penalty if I give the Ministre, an inquiry officer or reviewer any information that I know or should know is false or misleading
with respect to an application for a CAQ;
refuse any application that contains false or misleading information or document;
refuse to consider an application for a certificate from a person who has provided false or misleading information or
documentation within the past five years relative to an application under the Act respecting Immigration to Qubec;
cancel a CAQ if the application contains false or misleading information or document, when the certificate was issued by
mistake, or if the conditions required for the issue cease to exist.
I pledge to pursue the program or the level of studies indicated in this application.
I pledge to make my studies my principal activity (full-time studies) (1).
I also pledge to maintain, throughout my study stay in Qubec, medical and hospitalization insurance
the members of my family who are accompanying me, where applicable.

(2)

for myself and each of

I authorize the Ministre de l'Immigration et des Communauts culturelles to transmit to the educational institution where I will be
pursuing my studies the information relating to my Qubec Acceptance Certificate (CAQ) for studies. This information includes
the CAQ for studies number, the validity period, and the program of studies or level.
I authorize the Ministre de l'Immigration et des Communauts culturelles to release any information related to the processing of
my application for Qubec Acceptance Certificate for studies to the following person:
jaquenoud stengel, Aude
860 East Lake Rd, Ludlow (Vt), 05149, tats-Unis d'Amrique
Signed in:
City

Country

on the
Year / Month / Day

Signature of applicant:
Signature of the parent or legal guardian:
(Also required if the student is under 18 years of age at the time the application is made.)

(1) Temporary workers and members of their family, asylum seekers and members of their family as well as members of the family of foreign

students are exempted from this condition.

(2) The student and his family who benefit from medical and hospitalization insurance in Qubec under a social security agreement are

considered to comply with this commitment.

Ministre de l'Immigration et des Communauts culturelles

Declaration of financial support

If your application must be accompanied by proof of financial capacity, according to the OPTION that corresponds to your situation,
this declaration must be completed and signed by any person who will be paying the expenses related to your study stay in
Qubec.

Student or
minor child:

I, the undersigned

Stengel, Noelle

1995-08-17

Family name and First name

Date of birth

jaquenoud stengel, Aude

Family name and First name of the person taking financial responsibility for the student or minor child

residing at
No.

City

Who am:

Apt.

Street

Postal Code

Country

a permanent resident of Canada

other nationality / citizenship

a Canadian citizen
(specify)

hereby commit to cover all costs related to the stay of this student or minor child in Qubec, and more specifically:
to defray his costs of lodging, food, clothing, and personal necessities and/or to house him in my home, feed, clothe, and
provide for personal necessities for him, at no cost to this student or minor child;
to defray the costs of schooling fees and other expenses related to the studies, as required by the institution that he attends
during his stay in Qubec, including additional costs that apply to foreign students, if applicable;
to defray his transportation costs in Qubec, and from Qubec to his country of origin or to another destination at the end of his
stay in Qubec;
to subscribe to private medical and hospitalization insurance coverage in Qubec in order to cover his medical expenses, and
to maintain this insurance for his entire stay in Qubec.
This commitment is valid for the duration of the Qubec Acceptance Certificate (CAQ) for studies.
I understand that the minister may:
confirm, or have a third party confirm, the accuracy of information provided, and that I am breaking the law and am liable to a
penalty if I give the Ministre de l'Immigration et des Communauts culturelles, an inquiry officer or reviewer any information
that I know or should know is false or misleading with respect to an application for a CAQ;
refuse any application that contains false or misleading information or document;
refuse to consider an application for a certificate from a person who has provided false or misleading information or
documentation within the past five years relative to an application under the Act respecting Immigration to Qubec;
cancel a CAQ if the application contains false or misleading information or document, when the certificate was issued by
mistake, or if the conditions required for the issue cease to exist.

Signed in

on the
City

Country

Signature:

Ministre de l'Immigration et des Communauts culturelles

Year / Month / Day

EXAMPLE OF A BANK LETTER

(on Bank letterhead))
CERTIFICATE

We, the undersigned (bank's identification and contact information), certify that our client, Mr./Ms. (identification), holder of an
account at our institution with a current balance of _____________________ (specify currency), has the financial capacity to pay
all of the costs related to the studies in Qubec of ______________________________________________________
(identification of student), including:
the transportation costs (round-trip from/to country of origin);
the settlement costs for the first year (CAN$500).
and for the entire period of the student's program of studies in Qubec, which will be:_______________(1):
the living expenses (a minimum of CAN$11 825/year in 2014).
the annual tuition fees in the amount of_________________________________(2).

Signed in

Family name

on

First name

Title

Signature:

(1) Specify the time period in months or years.

(2) Indicate the amount in Canadian currency as indicated in the letter of admission from the educational institution.

personalized checklist
Stengel, Noelle

No. of the CAQ application:

207216

List of documents to be forwarded with this checklist to complete your application for a CAQ for study.

Check the boxes to make sure you haven't forgotten anything.

The original Declaration, commitments and authorizations form, dated and signed.

Staple here

PHOTO
MANDATORY

An original recent ID photo, passport format (35 mm x 45 mm), with your name on the back and
stapled in the box opposite.
Legible photocopy of pages of your passport bearing personal information and the photo (well
defined). Your passport must be valid.

Passport size
(35mm x 45 mm)

Official letter from the registrar of the educational institution that you attend establishing your full-time student status and the
number of credits obtained or to be obtained where applicable
Original of your marks transcripts from the educational institution in Qubec covering the entire validity period of your CAQ
for studies or copies certified true to the originals by the institution
Where applicable, an explanatory letter AND a document justifying the reason why your transcripts of grades do not show that
you studied full-time during this period.
Recent Declaration of financial support signed by the person who is covering the expenses related to your period of study in
Qubec
Recent and sufficient proof of that person's financial capacity to cover your living expenses, your tuition fees and other educationrelated expenses, including your health and hospitalization insurance costs
Check the documents you are submitting among the following eligible proofs:
Recent letter of employment stating that person's salary
Any recent statement of his assets (cash, investments: shares, units, bonds, etc.) and income
Recent paycheque stubs
Most recent notice of assessment from an income tax authority, stating his annual income
Bank letter(s) indicating his current balance
Bank statements
Recent authorization of funds transfer from the currency control authority of that person's country of origin or residence
Make sure you enclose all the documents listed above and your photo so as not to delay the processing of your application.
These documents will not be returned to you. Make sure you have other copies for your application for a Study Permit.
Any document provided must be in French or English or be accompanied by a translation into French or English signed and
certified by a professional translator.
Send your application to: Service aux tudiants
Ministre de l'Immigration et des Communauts culturelles
285, rue Notre-Dame Ouest, 4e tage
Montral (Qubec) H2Y 1T8
CANADA
Processing your application
Your application will be processed no later than four weeks following the receipt of your documents. To check your
application's progress, consult your file online.
If the decision is positive, you will receive two copies of your Certificat d'acceptation du Qubec (CAQ) for study, one marked
"Applicant" and the other marked "Immigration Canada," at your mailing address. You must enclose the copy marked
"Immigration Canada" with your application for a Study Permit to be sent to the Canadian immigration authorities.

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