McGill University



3417570115571REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY00REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY17145001143007151, Jean-Talon East, office No. 700Anjou (Québec) H1M 3N8 Phone: 514?351-27701?800?361-2001 Fax: 514 351-2658007151, Jean-Talon East, office No. 700Anjou (Québec) H1M 3N8 Phone: 514?351-27701?800?361-2001 Fax: 514 351-2658Document translated from French to English by McGill University with kind permission of OPPQImportantSave this document in your computer before completing it on your screen. Once the form is completely filled out, print it, sign it and include the date. Before submitting your application, make sure that you answered all the questions and that you attached the processing fees in order to process your request. Correspondence by email (scanned files, PDF or JPG format) to the following email address: rmonka@oppq.qc.ca or Correspondence by mail addressed to the Admissions Department at the address indicated above.For the use of OPPQ:PhotoDate of registration:Foreign diploma/ training:Applicant number:For the candidates trained outside Quebec who wish to obtain equivalence of degree or formation DATE OF THE REQUEST:TYPE OF LICENSE IN DEMAND: FORMTEXT ????? FORMCHECKBOX Physiotherapist (PT) FORMCHECKBOX Physical rehabilitation therapist (TRP)(yyyy-mm-dd)Personal informationNAME AT BIRTH:FIRST NAME: FORMTEXT ????? FORMTEXT ?????RESIDENCE ADDRESS (Street number and name, apartment): FORMTEXT ?????CITY, PROVINCE, COUNTRY:POSTAL CODE: FORMTEXT ????? FORMTEXT ?????HOME NUMBER: CELL PHONE:EMAIL ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DATE OF BIRTHSEX:SPOKEN LANGUAGE (S): FORMTEXT ????? FORMCHECKBOX F FORMCHECKBOX M FORMCHECKBOX FRENCH FORMCHECKBOX ENGLISH FORMCHECKBOX OTHER – Specify: FORMTEXT ?????(yyyy-mm-dd)LANGUAGE OF CORRESPONDENCE:CORRESPONDENCE ADDRESS IN QUEBEC:Street name and number, apartment: FORMTEXT ????? FORMCHECKBOX FRENCHCity, Province: FORMTEXT ????? FORMCHECKBOX ENGLISHPostal Code: FORMTEXT ?????Status FORMCHECKBOX Canadian Citizen FORMCHECKBOX Permanent resident FORMCHECKBOX Student visa FORMCHECKBOX Other – Specify: FORMTEXT ?????MEMBER OF A PROFESSIONAL ORDER FORMCHECKBOX No ↓ FORMCHECKBOX Yes→Province/State:Country:Work license number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Physiotherapy educationDEGREE WAS OBTAINED:YEAR OF COMPLETION:EDUCATIONAL ESTABLISHMENTCOUNTRY FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional completed training DEGREE WAS OBTAINED:YEAR OF COMPLETION:EDUCATIONAL ESTABLISHMENTFIELD FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????37719000REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY 00REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY Mandatory DeclarationsHave you ever been subject to a disciplinary hearing handed down in Quebec imposing a sanction by the disciplinary board of another professional order or by The Professions Tribunal or by an equivalent professional body in another Canadian province or abroad? FORMCHECKBOX Yes →Provide details:Nature of the infringement: FORMTEXT ????? FORMCHECKBOX No ↓Nature of the sanction: FORMTEXT ?????Name of the order or professional organization that made the decision: FORMTEXT ?????Date of the decision:File No:Province/ State:Country: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(yyyy-mm-dd)Have you ever been subject to a decision handed down in Quebec or by a court in Canada or elsewhere convicting you of a criminal offence or of an offence of a provision of the Statues of Quebec? FORMCHECKBOX Yes →Provide details:Nature of the infringement: FORMTEXT ????? FORMCHECKBOX Yes, and I obtained a pardon ↓Sentence given: FORMTEXT ?????Name of the court: FORMTEXT ?????Date of the judgment:File No:Province/ State:Country: FORMCHECKBOX No ↓ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(yyyy-mm-dd)Authorization FORMCHECKBOX I hereby authorize l’Ordre professionnel de la physiothérapie du Québec to provide my email address to training institutions that offer a physiotherapy program in Quebec. Knowledge of the French language (requirements of Quebec’s Charter of the French Language (L.R.Q., c. C-11, a. 35))I have completed, full-time, at least three years of school at a secondary or post-secondary level. FORMCHECKBOX No ↓ FORMCHECKBOX Yes → FORMCHECKBOX I studied for at least three years, full-time, at a secondary or post-secondary school that provides the teaching in French (high school, CEGEP, university); FORMCHECKBOX I passed the maternal French language tests at the fourth or fifth year at the secondary level in Quebec; FORMCHECKBOX I have graduated from high school in Quebec, starting from the school year 1985-1986.* Include any supporting documentation depending on the situationI have a certificate from Quebec’s French Language Office (OQLF) FORMCHECKBOX No ↓ FORMCHECKBOX Yes→Attach all required documents or hold a certificate considered an equivalent by the Government Regulations.Charges for file analysis and setupThe fees for file analysis and setup come up to 747,34?$ CAN, including taxes. It is to be noted that this amount does not include the fees of 172,46 $ CAN, including taxes, that would apply if, after analysing this application for the type of license outlined on page 1, a second analysis was made in comparison with the other type of license.PLEASE INDICATE THE METHOD OF PAYMENT (the fees must be paid and sent with the form): FORMCHECKBOX ChequeBy credit card (the applicant is the owner), with the following information: FORMCHECKBOX Money order FORMCHECKBOX VisaCard No: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Amount: 747,34?$ CAN FORMCHECKBOX Bank mandate FORMCHECKBOX MasterCardExpiration date (mm / yy): FORMTEXT ?????Signature:Solemn affirmationI certify that the statements in my application are true and I authorize their verification.Signature requiredDate27813007151, Jean-Talon East, office No. 700Anjou (Québec) H1M 3N8 Phone: 514?351-27701?800?361-2001 Fax: 514 351-2658007151, Jean-Talon East, office No. 700Anjou (Québec) H1M 3N8 Phone: 514?351-27701?800?361-2001 Fax: 514 351-26582171700REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY 00REQUEST FOR EQUIVALENCY IN PHYSIOTHERAPY IdentificationNAME AT BIRTH: FORMTEXT ?????FIRST NAME: FORMTEXT ?????List of elements to be provided with the application. Please identify them with a post-it according to the following numbering. Thank you for your cooperation! Elements to be providedIncludedNot Included Reason (required)Request for equivalency in physiotherapy, with picture (passport size) duly completed FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comparative Evaluation for Studies Done Outside Quebec (upon request by the Ministère de l’Immigration, de la diversité et de l’inclusion du Québec (MIDI)) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Curriculum vitae up to date FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Study of the successfully completed courses received, duly completed(physiotherapist or physical rehabilitation therapist) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Full academic record in the original language (French or English) or translated into FrenchCertified copy of the diplomas in support of the application FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Certified transcript of the grades in support of the application FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Titles of the courses of the university studies completed with respect to the practice of the profession (physiotherapist or physical rehabilitation therapist depending on the license desired) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Certificate of participation to continuing education activities or development activities with respect to the practice of the profession FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Titles of training and development courses completed with respect to the practice of the profession FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Work experience form duly completed, depending on the license desired (physiotherapist or physical rehabilitation therapist) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Work certificates with respect to the profession FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Certified copy of the work license, if applicable FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Proof regarding knowledge of French FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fees for file analysis and setup of the application FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? Mandatory item ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download