Date Application Received:

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1 FOR OFFICE USE ONLY Application/Registration Number: Date Application Received: Special Accommodation Application Received: APPLICATION FOR 2017 REGISTRATION EXAMINATIONS ACUPUNCTURIST (R. Ac) Please print clearly. Refer to the CTCMPAO Examination Guide available on CTCMPAO s website at INCOMPLETE FORMS WILL NOT BE PROCESSED AND WILL BE RETURNED 1. PERSONAL INFORMATION Mr. Ms. (Name must match the proof of identification) Legal First Name: Legal Middle Name (if any): Legal Last Name : Notarized Proof of identification attached Date of Birth: (mm/dd/yyyy) 2. CONTACT INFORMATION (all mail, including examination results, will be mailed to this address) Street No. & Name (Required) Suite No. City (Required) Province (Required) Country (Required) Postal Code (Required) Telephone (Required) Alternate Phone Fax *Please be advised that you must notify the College in writing within thirty days of any change of contact information. 3. ADDRESS FOR COLLEGE COMMUNICATION Address (Required) *Must be a unique address and cannot be shared with another applicant or member of CTCMPAO 4. EXAMINATION ATTEMPTS Check all that apply: First attempt Written Examination and Clinical Case -Study Examination First attempt Clinical Case-Study Examination Re-write Written Examination Province of last Examination Date of last Examination (mm/dd/yyyy) Designation of last Examiantion R. Ac R. TCMP Re-write Clinical Case-Study Examination Province of last Examination Date of last Examination (mm/dd/yyyy) Designation of last Examination R. Ac R. TCMP 1 P a g e

2 5. TESTING ACCOMODATIONS Please one box only Do you have any special needs which require accommodation (i.e., medical conditions, learning disability)? (Refer to CTCMPAO s Examination Guide and CARB-TCMPA s Candidate Examination Guide) Yes No If you answered yes, please complete the Testing Accommodation Application Form available on the CTCMPAO website. You will be required to attach supporting documents for your special needs. 6. POST-SECONDARY EDUCATION A. Education Program Proof of Education Completion: (You must attach all three of the following documentations if not submitted previously) 1. Attached a notarized copy of your degree, certificate or diploma in traditional Chinese medicine acupuncture or provide an original letter from your educational institution confirming successful completion of the program; and 2. Attached a notarized copy of your academic transcript of marks; and 3. Attached a detailed curriculum or course outline for your program, certified by your educational institution, including a detailed list of courses and a description of the content of each course completed during your education and training, including the number of clock hours. First Education Program Name of Program Name(s) and Address(es) of Education Institution(s) Attended Province Program Start date Graduation Date Total Program Hours Please complete the chart below. Identify the number of hours from your academic record / transcript demonstrating that your completed program aligns with the definition of full time education as defined in Section 1 of the Ontario Regulation 27/13 Registration. Please note that the supervised clinical experience is an additional registration requirement over and above the educational requirement. Refer to Guidelines for Evaluation. Year Completed Theory (Hours) Completed Practical (Hours) Supervised Clinical Experience (Hours) Total Hours Per Year P a g e

3 4 5 6 Total Combined Hours (i.e., year 1 + year 2 + year 3 + year 4) I have attached additional pages (if applicable) Second Education Program (if applicable) Name of Program Name(s) and Address(es) of Education Institution(s) Attended Province Program Start date Graduation Date Total Program Hours Please complete the chart below. Identify the number of hours from your academic record / transcript demonstrating that your completed program aligns with the definition of full time education as defined in Section 1 of the Ontario Regulation 27/13 Registration. Please note that the supervised clinical experience is an additional registration requirement over and above the educational requirement. Refer to Guidelines for Evaluation. Year Completed Theory (Hours) Completed Practical (Hours) Supervised Clinical Experience (Hours) Total Hours Per Year Total Combined Hours ((i.e., year 1 + year 2 + year 3 + year 4) I have attached additional pages (if applicable) 3 P a g e

4 Third Education Program (if applicable) Name of Program Name(s) and Address(es) of Education Institution(s) Attended Province Program Start date Graduation Date Total Program Hours Please complete the chart next page. Identify the number of hours from your academic record / transcript demonstrating that your completed program aligns with the definition of full time education as defined in Section 1 of the Ontario Regulation 27/13 Registration. Please note that the supervised clinical experience is an additional registration requirement over and above the educational requirement. Refer to Guidelines for Evaluation. Year Completed Theory (Hours) Completed Practical (Hours) Supervised Clinical Experience (Hours) Total Hours Per Year Total Combined Hours ((i.e., year 1 + year 2 + year 3 + year 4) I have attached additional pages (if applicable) B. Supervised Clinical Experience in Direct Patient Contact Proof of Successful Completion of Supervised Clinical Experience (if not submitted previously). Please note that the supervised clinical experience is an additional registration requirement over and above the educational requirement: An original letter from educational institution/supervisor confirming successful completion of at least 45 weeks of clinical experience in the TCM profession which involves at least 500 hours of direct patient contact. The letter must include a detailed description of the supervised clinical experience, showing the number of clock hours in direct patient contact and number of weeks spent in clinical training/experience. The letter must include the name and registration number of the supervisor with CTCMPAO (if applicable). *Please note. Applicants who complete formal education in Ontario after proclamation of the Traditional Chinese Medicine Act, which was April 1, 2013, are required to ensure that such supervision are performed by qualified members of CTCMPAO as per Section 29. (i) b. of Regulated Health Professions Act (RHPA). For more information, please refer to the CTCMPAO Examination Guide. 4 P a g e

5 *Please note. Applicants who complete formal education in Ontario after proclamation of the Traditional Chinese Medicine Act, which was April 1, 2013, are required to ensure that such supervision are performed by qualified members of CTCMPAO as per Section 29. (i) b. of Regulated Health Professions Act (RHPA). For more information, please refer to the CTCMPAO Examination Guide. Please complete the chart by listing the name of supervisors, registration number with CTCMPAO (if applicable) and the duration and location of the clinical experience. Supervised clinical experience (mm/yyyy mm/yyyy) Example: 09/ /2015 Name(s) and Contact Information for Instructor(s)/Supervisor(s) George Teacher m Supervisors Registration Number with CTCMPAO (If applicable) Name(s) and Address(es) of Training Site(s) for Clinical Experience R. TCMP 9999 ABC School of Traditional Chinese Medicine and Acupuncture 123 Avenue Street, Toronto, ON M5B 1S1 Province/City and Country ON, CANADA 5 P a g e

6 7. ASSESSMENT OF COMPETENCY Please complete the chart by listing name of courses from your academic record/transcripts demonstrating that your completed education program aligns to the required competencies as referenced in the Entry-Level Occupational Competencies for the Practise of Traditional Chinese Medicine in Canada. Based on your transcripts/academics records indicate the total hours of spent in each competency area. Core Competencies Name of courses that specifically addressed the competencies identified in each area Total hours Example: TCM Foundation TCM Theory of introduction hours TCM FOUNDATIONS DIAGNOSTICS AND TREATMENT ACUPUNCTURE TECHNIQUES 6 P a g e

7 Core Competencies Name of courses that specifically addressed the competencies identified in each area Total hours FUNDAMENTALS OF BIOMEDICINE INTERPERSONAL SKILLS PROFESSIONALISM SAFETY PRACTICE MANAGEMENT I have attached additional pages (if applicable) 7 P a g e

8 8. APPLICANT S DECLARATION I solemnly declare that the contents of this application including all attachments are true and complete to the best of my knowledge and belief. I understand and agree that if I make any false or misleading statement or representation on or in connection with my application, I shall be deemed not to have satisfied the requirements to write the Registration Examinations Pan-Canadian Examinations for Acupuncturists. I understand that I must notify the Registrar in writing within thirty days of any change of home and mailing address, phone number, and address. I authorize CTCMPAO to obtain information from other regulatory bodies, educational institutions, present and former employers, referees, any of my past and/or present treating regulated health practitioners, and any other sources for the purposes related to my application to write the Registration Examinations Pan-Canadian Examinations for Acupuncturists, including any experience and qualifications. Declared by: Name of Applicant (Please print) Signature of Applicant Date of Signature (mm/dd/yyyy) 8 P a g e

9 9. PAYMENT OF FEES Registration Examination Fees Application Fee (non-refundable) $ ($ $39.00 HST) Written Examination Fee $ ($ $58.50 HST) Clinical Case-Study Examination Fee $ ($ $45.50 HST) Note: Clinical Case-Study Examination Fee will be processed when all the eligibility requirements have been met. Method of Payment Payment Method 1: Credit Card (fill next section) Payment Method 2: Certified Cheque / Money Order (made payable to the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario Payment Method 1 : Credit Card If you are paying by credit card, fill out this section. Registration Number: Visa MasterCard Card number: Name on card (please print): Expiry date on card (mm/yyyy): / Security code (3 digit number on back of card): By my signature, I authorize the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario to charge my Visa or MasterCard account with the amount of $ in Canadian funds. Signature: 10. SUBMISSION OF APPLICATION Mail your complete application with payment and all necessary documents by the June 30, 2017 (5:00pm EST) to: Pan-Canadian Examinations CTCMPAO Commerce Valley Drive West Thornhill, ON L3T 7V9 *INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND THUS, WILL BE RETURNED. 9 P a g e

10 Application for Pan-Canadian Examinations Application Checklist A payment for Application Fee (non-refundable) $ ($ $39.00 HST) Written Examination Fee $ ($ $58.50 HST) Clinical Case-Study Examination Fee $ ($ $45.50 HST) Note: Clinical Case-Study Examination Fee will be processed when all the eligibility requirements have been met. Proof of identification (e.g. notarized copy of birth certificate, passport or a validation of identity signed by legal counsel.) Contact information address Examination attempts Testing Accommodation Information (If applicable) Information on Education Program including number of hours completed each year A notarized copy of degree, certificate or diploma in traditional Chinese medicine acupuncture or provide an original letter from educational institution confirming successful completion of the program A notarized copy of academic transcript of marks A detailed curriculum or course outline for TCM acupuncture education program, certified by educational institution, including a detailed list of courses and a description of the content of each course completed during education and training, including the number of clock hours Information on supervised clinical experience in direct patient contact including number of hours and weeks An original letter from educational institution/supervisor confirming successful completion of at least 45 weeks of clinical experience in the TCM profession which involves at least 500 hours of direct patient contact. The letter must include a detailed description of the supervised clinical experience, showing the number of clock hours in direct patient contact and number of weeks spent in clinical training/experience. The letter must include the name and registration number of the supervisor with CTCMPAO (if applicable). The Assessment of Competency including the name of courses that addresses competencies specified in each area and the percentage of theoretical and/or practical instructions Applicant s declaration (signature and date) 10 P a g e