Faculty Mobility Program Application Form

* denotes required field

First/Given name*
Middle name
Last/Family name*
Current telephone
E-mail address*
Name of Faculty and Department

Visit Information

Institution or country of interest (if known)
Proposed Departure Date
Proposed Length of Visit

Additional Information

Curriculum Vitae

Purpose of the visit and expected outcomes

The University of Regina collects information under the authority of The University of Regina Act and in accordance with the Local Authority Freedom of Information and Protection of Privacy Act and the Personal Information Protection and Electronic Documents Act for purposes of the administration of the University and its programs and services. By responding to this form, you are consenting to the University of Regina using your personal information (to/for ...describe specific purpose of information gathering on this form).