English Language Diagnostic Questionnaire

Declaration of Bilingual Competence: English Language
Students whose primary, first language, native language or dominant language is English, who
consider themselves fully bilingual, and who are applying for a program in administration,
cheminement bilingue, linguistics, English, translation or in teaching English as a second
language may complete and return this form, with their application, if they wish to be exempted
from the English placement test.
Program applied for: Baccalauréat en administration, cheminement bilingue (7364) ( )
Majeure en langue et linguistique (6632) ( )
Certificat inter-universitaire en langue anglaise (4425)
Certificat en traduction (6295) ( )
Programme court de traduction en anglais (0458) ( )
Programme court de traduction en français (0658) ( )
Programme court en enseignement de l'anglais langue seconde (0502) ( )
__________________________________________________________________________________________
Section A: General information
Last name: ________________________________ Given name(s):_______________________
Birthdate: D: ____ M: ____ Y: ____
Student I.D. #:_______________________ or New student: ( )
Address:________________________________City:____________________
Postal code:_________________
Telephone: Home: (
Country___________________________
) __________________ Office: (
) __________________________
E-mail:________________________________
______________________________________________________________________________
Section B: Education
Previous courses in English-speaking establishments (latest official diploma and transcripts must be
included)
Year
Level/grade Most recent
Province or
academic grades
country
English elementary/primary
school
English secondary school
English postsecondary/university
Section C: College or university level courses in the English
College or university English language courses (transcripts and course descriptions must be included)
Course title
Year
Level/grade
Most recent
academic grades
Province or
country
______________________
______________________
______________________
_____________________________________________________________________________
Section D: Other experiences in English
Other English language experience (please provide details and include your curriculum vitae)
(
(
(
(
(
) Work experience:
) Travel:
) Family:
) Live(d) in an English-speaking community:
) Courses (year, duration, name of institution):
Additional comments (experience in translation, teaching, etc.):
_____________________________________________________________________________________________
Section E: Declaration and signature
As a bilingual student, I request to be exempted from the English placement test.
Signature: __________________________________________Date:______________________________
Space reserved for UER Sciences Humaines, Lettres et Communications
The candidate is exempted from the English placement test ( )
The candidate must take the English placement test ( )
Commentary: ________________________________________________________________________
___________________________________________________________________________________
Authorized signature: _______________________________ Date: ______________________________