C-26, r. 215 - Regulation respecting the terms and conditions for the issue of permits by the Ordre professionnel des psychologues du Québec

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 5)

APPLICATION FORM FOR ISSUE OF A PERMIT

IDENTIFICATION AND PERSONAL INFORMATION

Surname: __________________________________________________________________________

(If the candidature for admission is a married woman, enter her maiden name)

Given name: ________________________________________________________________________

Address of domicile: _________________________________________________________________

City, Province: ______________________________________________________________________

Postal code: ________________________________________________________________________

Telephone: ( ) _____________________________________________________________________

Date of birth: _______________________________________________________________________

Sex Code

Male ( ) M

Female ( ) F

Native language Code Working language

French ( ) F French ( )

English ( ) A English ( )

Other ( ) X Other ( )

Citizenship or residence

Canadian citizenship ( )

Legally admitted to Canada to remain there permanently ( )

Other ( )

Permit to practice (in another province or state)

Ontario ( ) 1

New Brunswick ( ) 2

Another province or state ( ) 3

Specify: _______________________________

None ( ) 4

Are you a member of any other professional order or other association in Québec or elsewhere?

No ( ) Yes ( ) Specify? ________________________________________________________

Occupation (title of position): ___________________________________________________________

Employer’s name: ____________________________________________________________________

Address: ____________________________________________________________________________

City, Province: _______________________________________________________________________

Postal code: _________________________________________________________________________

Telephone: ( )______________________________________________________________________

UNIVERSITY STUDIES

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List your studies in chronological order:

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University Diploma Abbrev. Date granted

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TRAINING PERIOD: Have you served a training period in practical psychology?

Yes ( ) No ( )

If yes: number of credits ( ) or hours ( )

(1 credit = 30 hours)

Place(s): ____________________________________________________________________________________

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Supervisor(s): _______________________________________________________________________________

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THESIS: Title of thesis, dissertation or essay:

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Name of director(s): __________________________________________________________________________

University: _________________________________________________________________________________

Date submitted: ______________________________________________________________________________

PROFESSIONAL EXPERIENCE IN PSYCHOLOGY, if any

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Employer’s name Date (from - to) Position held

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OFFENCE OF A CRIMINAL OR DISCIPLINARY NATURE

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Have you ever been found guilty of a criminal offence by a Canadian or foreign court?

YES ( ) NO ( )

If yes, attach a certified true copy of the court judgment.

Has a disciplinary decision ever been rendered against you by the disciplinary council of a professional order in Québec or elsewhere?

YES ( ) NO ( )

If yes, attach a certified true copy of the decision.

I understand that a false declaration will cause my application to be rejected and that an application granted on the basis of false declarations is null.

I hereby apply to the Ordre professionnel des psychologues du Québec for the issue of a permit and I attest that the information provided herein is true.

Date: ______________________________ Signature: _____________________________________

O.C. 1837-94, Sch. 1.