C-26, r. 6 - Regulation respecting standards for the issue and holding of radiology permits

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 2)

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

O.C. 1210-87, Sch. 1.