APPLICATION FOR A RADIOLOGY PERMIT
I, the undersigned, ____________________________________________________________________
residing at __________________________________________________________________________
hereby declare that:
(1) I am entered on the roll of the Ordre professionnel des ___________________________________
(2) My consulting-room is located at ___________________________________________________
(3) I am enclosing with this application:
— 4 photographs taken within the last 6 months bearing my signature on the back;
— my academic record establishing that my training in radiology complies with section 2.
I request that the board of directors issue me a radiology permit under the provisions of the Professional Code (chapter C-26).
date member’s signature