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

Annexe Versions de la disposition

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.