T-5, r. 4 - Regulation respecting other terms and conditions for permits of the Ordre des technologues en imagerie médicale, en radio-oncologie et en électrophysiologie médicale du Québec to be issued

Schedule Disposition versions

2012-09-01

SCHEDULE I

EXAMINATION REGISTRATION FORM

INSTRUCTIONS

(1) Enclose the examination fee with your registration.

(2) Send the board of directors of the Order the duly completed attestation included in the training register at least 1 month prior to the examination date.

(3) Complete the form using block letters.

(1) Mr./Ms._________________________________ ___________________________________

Surname Given name

(2) Address of domicile _______________________________ ____________________________

Street Municipality

___________________________________________________________ _____________________

Province Postal code Telephone No.

(3) Date of birth: ___________________________________________________________________

Day Month Year

(4) Do you wish to take examinations:

in French _________ in Montréal _________ _________

in English ________ in Québec ___________ _________

in Rimouski

(June only) _________

(5) Discipline (please tick where applicable)

Radiodiagnosis _________

Radiation oncology _________

Nuclear medicine _________

(6) Candidate’s signature: ____________________________________________________________

Date: ______________________________________________________________________________

Day Month Year

TO BE COMPLETED BY THE COLLEGE

(7) I hereby certified that the candidate will have completed his technical training upon successful completion of his training period.

________________________________________ ________________________________________

Training coordinator CEGEP

________________________________________

Date

RESERVED FOR THE EXAMINATION COMMITTEE

(8) Date of receipt of form: __________________________________________________________

(9) Date of supplemental examination: _________________________________________________

(10) Signature of registrar: ___________________________________________________________

O.C. 177-92, Sch. I.