2022 Scholarship Application

Step One: Applicant Contact Info

First Name

Last Name

Date of Birth

Phone/ Number

Mailing Address

Address Line 1

Address Line 2

City/Community

Province/Territory

Postal Code

Country

Step Two: Tell us about yourself!

Where are you from, what are your planned areas of study, and what do you hope to achieve with your education?

Short Biography (Max 300 Words)

Arctic Co-ops is committed to diversity and inclusion and strives to ensure that awarded applicants are representative of the
communities we serve. Arctic Co-ops encourages interested applicants to self identify if they are a member of any minority
groups, including but not limited to: Indigenous peoples, persons with disabilities, visible minorities, and members of the
LGBTQ2S community.

Step Three: Co-op Affiliation

Are you a member of your local Co-op?

Is your parent or guardian an employee or member of your local Co-op?

Are you a current employee/volunteer at your local Co-op?

If your parent or guardian is a employee or member, please state their name:

Step Four: Demographic Survey

Arctic Co-ops is committed to equality, diversity and inclusion and recognizes the student population is diverse. We collect this
info solely to understand the audience applying.

Step Five: Education

Name of Highschool or Equitable Program

Year of Graduation

Check all that apply to you

This is my first time applying to a Post-Secondary Program

I am currently midway through my Post-Secondary Program

I have attended Post-Secondary before but did not complete the Program

I have attended Post-Secondary before and graduated from the Program

If you have attended a Post-Secondary Program before and Graduated, please complete the next three questions:

Name of Post-Secondary Institution

Name of Post-Secondary Program

Year of Graduation

Step Six: Aspirations

What is your planned area of study?

Tell us about your dream career (Max 100 Words)

Step Seven: Post-Secondary Info

Name of Program

Length of Program

Mailing Address of Post-Secondary Institution

Address Line 1

Address Line 2

City/Community

Province/Territory

Postal Code

Country

Step Eight: Funding

Is your Post-Secondary Program supporting you with any funding?

Are you receiving any other funding (Scholarships, bursaries, government support, etc.) for your studies?

If yes, state the amount:

If you are receiving additional funding, please describe below:

Funding Source #1

Funding Source #2

Funding Source #3

Amount

Step Nine: Consent and Declaration

I, the undersigned, hereby consent to the perpetual use by Arctic Co-ops and any affiliates of my photograph, likeness and/or any part of my submission including art, recordings and including, but not limited to, any of those identified above in the assignment section (the Submission) for the promotion or furthering the mission of Arctic Co-ops Post-Secondary Scholarship or for any other purpose in Arctic Co-op’s discretion. I understand that I will not receive separate compensation or consideration from Arctic Co-ops or anyone else for the permission granted in this Consent nor for the actual publication or use of my Submission. By signing this Consent, I understand I am releasing Arctic Co-ops from any and all liability that may occur as a direct or indirect result of Arctic Co-op’s use of my Submission, the release of my identity, or any public relations materials

I declare that the information provided in this application is true and correct. I understand that any wilful dishonesty by me may result in my application being denied or if such dishonesty is identified after any award of funds, such funds will be immediately due and owing to Arctic Co-ops. I confirm that I am a Canadian citizen and eligible to enroll in post-secondary education.

Name of Applicant

Date of Signing

Signature

Sign Here

If the applicant is under the age of 18, a signature from a Parent/Guardian is required.

Name of Parent/Guardian

Date of Signing

Signature

Sign Here

Step 10: Attach your files

Attach multiple files, up to a total of 4 MB.

Attach File(s)

If your attachments are better shared via a URL (ex. DropBox, Google Drive, YouTube, Soundcloud, etc.) please paste the link below.

Welcome to the 2022 Online Application Portal

The objective of the Andrew Goussaert Memorial Scholarship is to support to Post-Secondary students affiliated with communities within the Arctic Co-operatives Limited network.

Since you cannot save your application form and return, its best to prepare your materials before you begin.

Application Checklist