ACMDTT: Application for Registration for Internationally Educated ENPs

Application for Registration

Internationally Educated ENP Applicant
Section 1: Applicant Information
Legal Name*

First NameMiddle NameLast Name
Previous Name (maiden name etc.)

First NameMiddle NameLast Name
Proof of name change (government issued)

pdf, doc, docx, jpg, jpeg, png, gif
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Practice Name (if any)
Your preferred name in professional settings
Phone Number*

Country CodeArea CodePhone Number
Date of Birth*

DayMonthYear
Home Address*

Street Address / P.O. Box

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*

FemaleMaleSelf Describe
Email*
1. Valid government issued photo ID*

example: drivers license, citizenship card, permanent resident card or identification card
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2. Valid government issued ID*

example: birth certificate or passport
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Section 4: Language Assessment
- Section 9(1) of the Regulation requires that an applicant for registration as a regulated member must be reasonably proficient in English to be able to engage safely and competently in the practice of medical diagnostic and therapeutic technology.
Was your education instructed in English?*

YesNo
Supporting documentation

pdf, doc, docx, jpg, jpeg, png, gif
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Please note: If your qualifying education was instructed in a language other than English, upload your English language test results below.
English Language Test Results

pdf, doc, docx, jpg, jpeg, png, gif
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Section 5: Practice Hours
- Please fill out a Practice Hours Form(s) for each employer you've had for the past five years from the date of application.
- If you had multiple employers in the last five (5) years, each employer must verify a separate form.
- Download the Practice Hours Form. When completed, upload your form(s) below.
Have you graduated in the last two years and not yet started practicing?*

YesNo
Practice hours form (Employer 1)

pdf, doc, docx, jpg, jpeg, png, gif
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Practice hours form (Employer 2)

pdf, doc, docx, jpg, jpeg, png, gif
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Practice hours form (Employer 3)

pdf, doc, docx, jpg, jpeg, png, gif
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Section 6: Character Reference
- Please upload a reference letter from your current or former supervisor that will attest to your character regarding your work responsibilities.
- Read more about character reference letter requirements.
Character reference*

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Section 7: Professional Experience

7.1 Competency Checklist
- Download the Electroneurophysiology technology Competency Checklist
- Upload the duly filled and supervisor approved competency checklist.
7.1 Competency Checklist*

Multiple files may be uploaded in the this section
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7.2 Self-Assessment Form
- Fill out the Self-Assessment Form by clicking on it and attach it in the specified section below.
  
  Electroneurophysiology technology
7.2 Self Assessment Form*

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Application for Registration