First name

Name you will use in practice Other last name (if applicable)

Date of birth (month/day/year)

2. Current Residence Address

Street

City/Town Province/State Country Postal/Zip/Country code

Email Home telephone number Mobile telephone number

4. Academic Background

Physiotherapy Education

Degree type awarded University Province/State/Country Year

Degree type awarded University Province/State/Country Year

Education Other Than Physiotherapy

Degree type awarded Program Completed

University Province/State/Country Year

Degree type awarded Program Completed

University Province/State/Country Year

Registration as a Physiotherapist

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Application

Did you also complete a Canadian physiotherapist bridging program?If yes, where Year

1. Personal Information

Middle name Last name

Female Male

3. Residence History

Every country you have lived for 90+ days within 10 years of this application or dating back to your 18th birthday.

Country AND Date Range (month/year) Country AND Date Range (month/year)

Country AND Date Range (month/year) Country AND Date Range (month/year)

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5. Physiotherapy Competency Examination

6. Practice Hours

Hours practiced as a physiotherapist during the last 5 years.

7. Language Proficiency

Languages, other than English, in which you can provide physiotherapy services.

8. Employment History

Details of employment as a physiotherapist for the last 10 years. Please list any Canadian or international employers.

Employment dates (start-end) Position

Employer name

Street City/Town

Province/State Country Telephone

Employment dates (start-end) Position

Employer name

Street City/Town

Province/State Country Telephone

Employment dates (start-end) Position

Employer name

Street City/Town

Province/State Country Telephone

Written Component Date Clinical Component Date

Passed on: Passed on:

Results pending for: Results pending for:

Unsuccessful attempt on:

Unsuccessful attempt on:

I have not completed the Physiotherapy Competency Examination.

Oct 2014 - Spt 2015 Oct 2015 - Spt 2016 Oct 2016 - Spt 2017 Oct 2017 - Spt 2018 Oct 2018 - Spt 2019

French Other

10. Alberta Employment

Complete this section if you have accepted employment as a physiotherapist in Alberta at time of applying.

Anticipated start date Title/position

Name of facility where you will work

Mailing address of facility (street, city/town, postal code)

Telephone number Contact

Work relationship with employerOptions to choose from:

Permanent, temporary, casual or self-employed.

Status based on hours workedOptions to choose from:

Full time or part time.

Focus of activitiesOptions to choose from:

Clinical: cardiovascular and respiratory system, musculoskeletal system, neurological system, skin and related structures, more than one system. Non-clinical.

Age range of patients served in clinical practiceOptions to choose from:

Paediatrics, adults, seniors, all ages.

Area of practice [select up to 4]Options to choose from:

Administration, amputations, burns and wound management, cardiac rehabilitation/care, chronic disease prevention and management, chronic pain, client service management/case management, concussion, consultant (without direct client service), critical care, education directed to providers, ergonomics, gerontology, health promotion and wellness, inpatient general practice (facility based), motor vehicle collision injuries, neurology (adult or pediatrics), oncology, osteoporosis, outpatient orthopedic practice (general, lower extremity, spine or upper extremity), palliative care, pelvic health (internal examinations), plastics/hands, research, respiratory care, return to work rehabilitation, rheumatology, scoliosis, sports medicine, TMD, vestibular rehabilitation.

Primary: Other:

Other: Other:

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9. Registration

List the regulatory organizations where you have been registered/licensed as a physiotherapist, or another regulated professional, for the last 10 years: name of organization, profession, province/country, registration dates, registration number.

11. Good Character + Reputation Declarations

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A. Are you currently involved in an inquiry or proceeding respecting your practice as a physiotherapist, or another regulated professional, in any jurisdiction? An inquiry or proceeding can include, but is not limited to, appearance before a regulatory panel or employer committee or panel, investigation, alternative complaint resolution process, hearing or appeal.

If yes, provide details including whether there are current terms, conditions or restrictions on your license/permit because of the inquiry or proceeding.

B. Were you previously involved in an inquiry or proceeding respecting your practice as a physiotherapist, or another regulated professional, in any jurisdiction which resulted in actions against you. An inquiry or proceeding can include, but is not limited to, appearance before a regulatory panel or employer committee or panel, investigation, alternative complaint resolution process, hearing or appeal.

If yes, at the conclusion of the inquiry or proceeding, what was the outcome?

What is the current status of the outcome, e.g. concluded, outstanding?

C. Have you ever had an application for registration as a physiotherapist, or another regulated professional, refused?

If yes, provide details.

D. Have you ever been charged, pleaded guilty or been found guilty of a criminal offense in any jurisdiction?

If yes, provide details.

E. Has there ever been a judgement in a civil action made against you with respect to your practice as a physiotherapist or another regulated profession?

If yes, provide details.

Yes No

Yes No

Yes No

Yes No

Yes No

I declare that the information on this application is true and complete to the best of my knowledge. I understand a false or misleading statement may disqualify me from registration or may be cause for revocation of any registration for which may be granted to me. I agree to inform Physiotherapy Alberta if any of the information reported on this form changes between now and the date my registration is approved.

Signature Date

13. Applicant's Declaration

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Submit your completed application by: Email: registration@physiotherapyalberta.ca Fax: 780.436.1908 Mail: Physiotherapy Alberta - College + Association

Suite 300 Dorchester Building 10357 109 Street, Edmonton AB T5J 1N3

COMPLETED APPLICATION

12. Payment

The application and practice permit fee may be charged to the credit card below.

MasterCard Visa

Credit card number Expiry date (mm/yy)