REGISTRATION Application for a Registration Certificate The Office of the Admissions and Registrar

INFORMATION Before you fill in this form, please read all the information on the back very carefully.

IDENTIFICATION

Last Name: Permanent Code: ABCD 12345678

First Name: File Number: Or Equivalence File Number 123 123

Address: Apartment:

City (Province): Postal Code:

Email: Telephone: (123) 123-1234

CONSENT Communications from the OIIQ and regional orders: In accordance with the new Canadian anti-spam legislation, I expressly agree to receive, by e-mail, communications from the OIIQ and my regional order informing me of their activities and which may contain offers from their commercial partners (e.g. offers of continuing education courses).

O Yes O No

Communications from OIIQ partners and regional orders: I agree that the OIIQ may disclose my name, address, telephone number and e-mail address to firms with which it has partnership agreements to benefit its current and future members (e.g. banking services, home and automobile insurance), so that those firms can contact me directly, in particular by e-mail.

O Yes O No

Communications for purposes of research, surveys or statistics: I agree that the OIIQ may disclose my name, address, telephone number and e-mail address to third parties for purposes of research, surveys or statistics, so that those third parties can contact me directly, in particular by e-mail.

O Yes O No

TRAINING PROGRAM

Institution Name: Admission Date:

JUDICIAL, DISCIPLINARY OR PENAL DECISION You must inform the Secretary if you have been convicted of a criminal, disciplinary or penal offence in Canada or another country:

Have you been convicted of a criminal offence in Canada or another country? O Yes O No

Have you been convicted of a disciplinary offence in Canada or another country? O Yes O No

N.B. This must be a disciplinary offence of which you have been convicted by the disciplinary council of another order, i.e. not the OIIQ.

Have you been convicted of a penal offence related to unauthorized use of a reserved title or unlawful practice ofa profession in Canada or in another country?

O Yes O No

DECLARATION AND SWORN PROMISE О I solemnly declare that the information that I provided in this form is true, accurate and complete.

О I have been duly advised that any false declaration on my part may lead to the revocation of the registration certificate.

Signature: Date of signature:

MEANS OF PAYMENT – REGISTRATION CERTIFICATE Administrative fees are $ 224,20 (taxes included). These fees are non-refundable and are subject to change without prior notice.

Last Name: Permanent Code:

First Name: File Number: Or Equivalence File Number 123 123

О Cash / Interac (OIIQ front counter) О Credit Card (please fill in the following fields)

Holder Name: Number:

Type: Expiry Date:

Signature: Date of signature:

This completed, printed, signed and certified form must be returned along with all the requested documents and payment to the following address: Ordre des infirmières et des infirmiers du Québec, The Office of the Admissions and Registrar, 4200 Molson St., Montréal, Quebec H1Y 4V4.

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REGISTRATION Application for a Registration Certificate The Office of the Admissions and Registrar

INFORMATION In order to send us clear and accurate information, please make sure you fill in the form online and print it out. You need to fill in all the grayed-out fields and answer all the questions. Any incomplete form will be returned to you.

All students must enter their names on the list of holders of registration certificates, as of the beginning of studies in order to receive their registration certificate. In all cases, they must have received an email confirming their registration before admission as a trainee in a clinical setting.

All graduates from outside Québec who must attend a training program to obtain a full training equivalence must have a certificate. In all cases, they must have received an email confirming their registration in their possession before beginning their training program to be covered by the professional liability insurance while in training.

IDENTIFICATION The OIIQ will send any documents intended for you to this email address. Consequently, it is important that you immediately notify the OIIQ of any change in your contact information.

JUDICIAL, DISCIPLINARY OR PENAL DECISION You must inform the Secretary if you have been convicted of a criminal, disciplinary or penal offence in Canada or another country.If you answered “yes” to any of the above three questions, the Executive Committee will have to analyze your file, to determine whether it will authorize the issue of a registration certificate despite these infractions. You must provide the Secretary with any document she requests and your file, once complete, will be presented at a next meeting of the Executive Committee. Consequently, it may take several weeks for your application to be processed, so you must complete this form and submit it to the Office of the Admissions and Registrar.

DOCUMENTS TO BE SUPPLIED In order to be processed, your file must be complete. It is therefore your responsibility to provide the OIIQ with the following documents, all sent together:

The Application for a registration certificate form, duly signed;

The Payment;

The certified copy of the child's birth registration.

BIRTH CERTIFICATE If you were born in Québec, enclose your birth certificate issued by the Directeur de l’état civil. Photocopies will not be accepted. In Québec, the birth certificate request form can be obtained through: Direction de l’état civil, on the Web site www.etatcivil.gouv.qc.ca.

If you were born outside Québec, if you have already sent your birth certificate to the OIIQ, you do not have to provide it (for outside Quebec graduates):

the copy of your birth certificate must be issued and certified by the organization that issued the original document or an authorityempowered to certify documents of identity and civil status in the country of origin, e.g. a local government or notary public; – if you are not sure about the authority empowered to certify such documents in the country of origin, consult the website of the Ministère de l’Immigration, de la Francisation et de l’Intégration, where you will find a list of recognized authorities for each country www.immigration-quebec.gouv.qc.ca/fr/formulaires/formulaire-titre/liste-autorites.html.

note that copies certified by an embassy or consulate of your country of origin will be accepted.

If you wish the original certificate to be returned to you, make sure you also include a self-addressed and stamped return envelope. If you do not include a return envelope, the original will be destroyed after your file is processed.

DOCUMENTS IN A LANGUAGE OTHER THAN FRENCH OR ENGLISH Any document in a language other than French or English must be translated by a translator certified by the Ordre des traducteurs, terminologues et interprètes agréés du Québec (OTTIAQ). You can consult the list of certified translators at www.ottiaq.org.

You have to provide us the original translation.

MEANS OF PAYMENT – REGISTRATION CERTIFICATE The only authorized means of payment are in cash/by Interac at the OIIQ front counter or by credit card – please fill in the required fields. Your application will not be processed if you fail to follow instructions for the means of payment.

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