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 II

SUPPLEMENTAL EXAMINATION REGISTRATION FORM

INSTRUCTIONS

(1) Enclose the examination fee with your registration.

(2) 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 examination:

___________________________________________________________________________________

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)

Radiography _________

Radiation oncology _________

Nuclear medicine _________

(6) Candidate’s signature: ____________________________________________________________

Date: ______________________________________________________________________________

Day Month Year

RESERVED FOR THE EXAMINATION COMMITTEE

(7) Date of receipt of form: ___________________________________________________________

(8) Date of supplemental examination: __________________________________________________

(9) Signature of registrar: ____________________________________________________________

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