C-16, r. 8 - Regulation respecting professional examinations of the Ordre des chiropraticiens du Québec

Schedule Disposition versions

2012-09-01

SCHEDULE B

(s. 12)

(Graphic symbol)

ORDRE DES CHIROPRATICIENS DU QUÉBEC

Form for registration in a professional examination

To the board of directors of the Ordre des chiropraticiens du Québec

I, _________(surname)_________ _________(given name)_________ domiciled at _________(number)_________ _________(street)_________ _________(municipality)_________ _________(province or country)_________, hereby apply for registration in the professional examination to be held on ___________________________

I undertake to comply with the Chiropractic Act (chapter C-16), the Professional Code (chapter C-26) and any regulations made under those Acts.

GENERAL INFORMATION

Surname of candidate (at birth) _________________________________________________________

Given names _______________________________________________________________________

(Where the name has been changed since)

Present surname of candidate __________________________________________________________

Given names _______________________________________________________________________

Date of change of name ______________________________________________________________

Permanent address __________________________________________________________________

Telephone _________________________________________________________________________

Present address _____________________________________________________________________

Telephone _________________________________________________________________________

Photograph signed on the front

Marital status: Single Married Other

Name of spouse (if married): __________________________________________________________

Name of father: _____________________________________________________________________

Name of mother: ____________________________________________________________________

Date of birth: _______________________________________________________________________

Place of birth: ______________________________________________________________________

Citizenship: ________________________________________________________________________

Mother tongue: _____________________________________________________________________

Languages spoken: __________________ written __________________ read __________________

understood orally ___________________________________________________________________

Have you had at least 3 years of instruction starting from secondary school level in an institution where the instruction was given in French?

Name of institution __________________________________________________________________

Courses taken ______________________________________________________________________

Have you practised chiropractic outside Québec?

Yes: _____________________________________ No _____________________________________

If yes, where? ______________________________________________________________________

Have you ever been disciplined for any reason related to the practice of chiropractic?

Yes: _____________________________________ No _____________________________________

(If yes) name of body that imposed the penalty: ___________________________________________

__________________________________________________________________________________

Date of penalty: _____________________________________________________________________

Nature of infraction: _________________________________________________________________

Sentence imposed: __________________________________________________________________

I declare that all the information in this questionnaire is complete and accurate.

In witness whereof, I have signed at __________(place)__________ on the ____________________

_____________________________________________

(candidate)

Sworn or declared before me, at ___________________________, this __________________________ day of ______________________________ 20__________

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(Commissioner for oaths)

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O.C. 270-87, Sch. B.