O-6, r. 6 - Regulation respecting terms and conditions for a permit to be issued by the Ordre des opticiens d’ordonnances du Québec

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 2.01)

ORDRE DES OPTICIENS D’ORDONNANCES DU QUÉBEC

Application for permit

I, the undersigned, swear that the answers below are complete and true.

(1) ______________________________________________________________________________________

surname and given name indicated on birth certificate

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other given names

______________________________

social insurance number

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name generally used

(2) Home address:

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number street

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city/town province postal code

______________________________

telephone

Present address:

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number street

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city/town province postal code

______________________________

telephone

(3) Have you legally changed name? Yes__________ No__________

If so, state your former name ______________________________

(Please attach copy of pertinent legal documents).

(4) If not born in Québec, how long have you been in Québec? ______________________________

Where applicable, are you naturalized? Yes Yes__________ No__________

(If so, attach copy of certificate).

(5) Your civil status:

Single:____________________ Married:____________________ Other:____________________

(6) Educational establishment(s) attended:

College level:

Number of years:______________________________

Name of educational establishment:______________________________

University level:

Number of years:______________________________

Name of educational establishment:______________________________

(7) I attach to this application:

(a) my birth certificate;

(b) my diploma of college studies in ocular prosthesis techniques or an attestation of the obtainment of such diploma, or an attestation that my diploma or my training has been recognized equivalent by the board of directors.

(8) I undertake to comply with Dispensing Opticians Act (chapter O-6) and the regulations.

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signature

Sworn to before me at ____________________ this __________ day of _____________________20__________

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commissioner for oaths

R.R.Q., 1981, c. O-6, r. 6, Sch. 1.