jinky copies of returning docs. feb. 26, 2012

8/2/2019 Jinky Copies of Returning Docs. Feb. 26, 2012

1/6

ION FORML^kraile.vi"ru'il|I,'qtoto^cvi".* JcECEp oHN ABBoiifiiircr $ enoenana,ruMBER:-A.E.c.wA.oK-pRocRAMAME:-pRoFEssroNALNrEGRArtoNURSTNGRocm

.ENTER FoR coNTtNulNG EDUcATton E enoennuNUMBER:A'E.C. CWA.OD-pRoGMMNAME: REFRESHERURSINGRoGRAMStudentNumber:Permanent ode Letters Numbers tlS e x M l F

Day Month Year[nrnlnarofbir th I l l I l l | |Langua.ge Fj$cH EN6usrorxrnn o r n a r y l l l l l is p o k e n l L l 2 L _ _ j 3 L l

Familvname'at birth

Usual ivenname .'I ;"ff";-othertongueStreet Rural oute / P.O. ox

PhoneNo. at workORcell Telephone umber LocaltT-n T-mm-rPlac of ormnnt 1 | | P16y;ns of Quebec 2 I I Elsewheren Canada 3 I lOutsideCanada:residncenJan 1st, 012

Placeof birth: rtc.*auLegalStatusof Residencen Canada:fl CanadianCitizenSpecifu:

t f-l canadian 2 [-l emerindian 3 [-l tnuitI otner Specify:4 fl Permanentesidents f-l student isa

s I oter

1. Have you ever taken or aneyou takingcourses in a collegial level institution?

7 l-l Member of Diplomatic FamilyI L-J Refugee9 | I Temporary Work Permit

r ! vesz IHo

OfficialDocument Yourprincipaloccupationduring the last six months(check ne box only):1 f_-] studies 2 [---.lwork 3 f_-l other

lf yes a) Nameof last nstitution attended:b) Areyou presentlyattendingthis institution? r Ives zI ruo

2. Last year of studies completed. or now in progress, before entering a collegial level institution.t l-l tess han Secondary + f-l Secondary Nameof the institution:z l-l Grade t D'E's'oR D'E'P' Nameof the schoolboard regional):s [-l crade z s I otner specify:

3. Number f school ears ompleted:-I herebydeclarehat the informationgivenabove sconect. I authorize he College o verify the documents ndudedor other informationrequested.t officilly eclareht I am aking his irst coursen the aboveDEC r AEC rogramwith the specific oalof erntuallybtaininga Diploma fCollege tudiesn thisprogram.


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DEMANDED'VALUATION OMPARATIVE ES TUDESEFFECTUESHoRsououeEc ETDEREcoNNAlssAruce'QUIvALENcE ononEDEs nrtnutREs T NFIRMIERSuoueec(ollo)APPLI/CATI/ONORA COMPARATIVEEUALUAT'ONOF STUD'EScoMpLETEDttrstar ouaecAND oRRacocutnouoFEeu,uALENcEBv rHE aRDRE DEs tNF,RMtnesET INFIRMIIERSououeEc ,,a)

1 . N o m /Name.'2. Nom/Name:

ldentique l'acte de naissance As it appearson birth certificate

Province Pays/Country

Prnom(s)/Given name(s):Prnom(s)/Gvenname(s):Nom utilis, i diffrent e celui ndiqu la ligne 'Nameused, f different rom the name enterd on line l.

AdresseAddress: NumEroTx6.

4- Dateenaissance/ T-Tl-lDatefbirth: L^-#aeiji [nl lMois/ MonthFranais/ [lFrench | |Masculin/ nMale | |

n-nr-node postal/PostalcodeAnglais/English

lravail/Work

Pavs e naissancelCountry of birth:

5. Langue e correspondance/Language f corresPondence

t6. Sexe/Sex:

8. Adresse e courrierlectronique/Emailaddress:

t--lremrnrn/ I IFemale I I7 rrphone/-T-l-l rT-n[_Tl-flTelephone:-I{.f,;ftfr;| r-l-r-tTr [-n] rT-nl-nnTellulaire/ Mobile9. Avez-vous j ai t unedemande 'valuation omparative estudes ffectuesorsdu Qubec.auministre e l'lmmigration t desCommunautsulturell" tr,.,1rcClu undemande e reconnaissance'quivalence esdiplmes t de la formation l'Ordredes nfirmires t infirmiers u Qubec OllQ)?Haveyoupreviouslysubmittedanapplicationioraannparativeevaluatiottot.studiesc


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ruoesEFFEcruesAaADEM,cAcKcRoUND

lo. fUotS PRIMAIRESNe pas oindrede diplmesni de relevsde notes)ELEL'IENTARYfUDrES (Do not enclosediplomas or transcripts)PayslCountry Priodc d6 ud6/ WIen attencrdrablissenentd'enseignemnt/Nane of iniinrtion villelCitr

Anned'obtentiondu diplre, s'il y a lieu/ueardiplom odinfi, if applicableLangue 'enseignment/LnBuage f instructionDiplm obtenuou demireanned'tuds ussie/Diploru eamed or larl yeard succsfully completedstudi

11. TUDES ECONDAIRESSECONDARYTUDIES n; T-l-fl+:T-t-Priode dc nrdes/Wlen anerffitablissement'emei8menl/Nameof institution P*lCunWDiplre obtenuou anned'tudc ussiey' Ann dobtentionDiplma eamed or la yw of succdully comdad saies Yeardiplura laid ad atbit

et domaim Laneuad inslruclip;;T-fn +tPriode destuds/Wtm atnddtablissement'ensi8rent/Nare of inqitution

Anne d'obtstion du diplme et dwlaireYan diplma aired rrd flbjtI tangua$Diolmeohenu ou demireann d'tud6 russie/Dioluna eamd u la yar of succsully complad audi

Pays Counlry

Etablissemnt d'm*ignffi t/Nareof i$tiluti

t Z. ruOeS pOSTSECONDAIRESTechniques/Professionnelles/ niversltaircaPOSi-SECONDARYSr|.JDIES fechnical / Profional Univercity

PayslCunW Priode dtuds/WlEn ltended

innruc,.iM*; [T]]] +tTTVillelCrty PyslCounlry Priodeds tudes/ Wlwt atterdrdIablisement 'igmnt/Nare of insiinnkm

Diplme otrrmu u denire anDc Anne d'obtentim du diplme d domiDiplom med or lt yearof ws/ully onrylad avdis Yeardiplwra &aid atil subitI Langre9e of ir/,nrc',i

# [T-i-fl +!-T-ttablis*mentd'eiSnement/Nare of iniluti Priode des tuds/ Wh adtndedLangue d'eigneml I LanSWe o{ i,EatttcliDiplme obtflu @ demirc nne d'tud6 63ie/Diploma md or lasayear of rccfully conplaed studi Anne d'otiention du diolme et domaiYar diplomtai'd and snbit ?eys/ Counlryd?reignerent/ Pfiode d6 tudes/whan anendd

/ tanguqe of insucti@ffie obtenu mire anned'tdc qsie/ Anned'obtenriondu diplmeet domiOiplm eand or lag yearof rcfully conpleted satdi Yeardiplom ohained and subit

Priodeds d6/ WlEn ansdedtblisffi nt d'ensiSnement/Ndre ol inslitutionobtenuou dsnire anned'tud6 r6sie/ Anne d'obtention du diplre erOiploma eamedor lastyear of succdully co,nPleted sludir Yar diploma o&ained and subiea

Paysl Cuntry

br4d'eneigmnt/ of i'drudkm


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AUTHOBIZAT'ON O RELEASEPERSONALNFORMATIONThepersonal nformation contained n this orm is required to process our application for a comparative evaluation oi studiescompleted outsideQulcand iorrecognition f equivalenceof dip lomas and training.In this egard,someof the nformationcan also be usedby the Minister esponsible or theapplication of the Act respecting he ministrede l'lmmigrationet desCommuniutsculturelles or study or statistical urposest rogramevaluation,or to give you information that may help you become established nd integratedinto Qubec society.Accesso this nformation s restrictedo authorizedpersons nder theprovisionsof the aw, namely he Act respecting ccess o documentsheld by public bodiesand heprotection f personalnformation R.$.Q., . A-2.1),and theCivil Codeof Qubec'you have the lght to be intbrmed oi the nt'ormation that concernsyou, ancl, f necessaryto correct any inaccuracies by addressinga wriften request o the otticeresponsibleor processing ou rcquest.The oersonalnformationcontained n your record s confidentialand may notbe disclosedwithout your authorization,unless he aw indicates thetwise'

In view of the foregoing and n order to facilitate theprocessingof my application for a comparative evaluation of studiescompleted outside Qubec by theMinistre e t'lmriigrationet des Communauts ulturellesand for recognitionof eguivalenceof my diplomasand training by the Ordre des nfirmires t infmiers du Qubec, authortze:TheOrdre des nfirmires t infirmiersdu Qubec o send hiscompleted orm to the Ministrede l'lmmigration et des Communauts ul turellesalong withthe documents (identifcation, academicdocuments,and translation, if needed)required ior processin1my application for a comparative evaluation of studiecompleted outside Qubec;The Ministre e I'lmmigrationet desComntunauts ulturelleso send he Ordre des nfirmireset infirmiersdu Qubeca copy of their comparativeevaluaof the studies comptetd ouside Qubec, or, as the casemay be, a copy of the letter nforming me of their inabilty to pertorm a comparative evaluation ofthe studies completed outside Qubec'

Signature Date

I understandhat:. lt is my responsibilityo obtain andprovide the nformation and documentsequired or the study of my application for a comparativeevaluationof studies omplI oultsii"eieAec an for recognitonof equivalenceof my diplomasand training o the Minstre e l'lmmigration et des Communauts ulturellesand heOrdre des infirmireset infirmiers du Qubec;o The Ministre e l,lmmigrationet des Communauts ulturellesmay contact he educational nstitutions aftendedor thegovernmentauthorities esponsiblih" tr"inirg I received t'r thepurposeof obtaining or verifying,, f necessary theinformation conceming,my studies and the academic documents submifted fthe proceslng f my applicaton or a comparativeevaluationof studiescompletedoutsideQubec;. The processingime for my requestwill be extendedif t have not supplied all the information and documentsrequired or if informaton requestsor verificati.uri be carrd outwith ihe educationa! nstitutions attendedor with thegovernmentauthorities esponsible or the training received;. The ees equred or processingmy file are non refundable;. The Ministre e I'lmmigration et desCommunauts ulturellesmay chargeaddtional ees or tftnslationpurposesor for verificationof a translation;o Academic documentswith changes,correctionsor deletionsmay be refused;. The Ordre des nfirmires t infirmiers u Qubecmay contact theschools attended, heorganization hat ssuedmy permit or registeredmy diploma ormy employers to verify information aspart of theprocessfor recognizing the equivalence of my diplomas and training;. If I haveprovided false nformation or forged or altered documents:. The Ministre e l'lmmigration et des Communauts ulturellesmay refuse o issue n valuation onrparative estudeseffectues ors du Qubec;

. TheOrdre des nfirmires t infirmiersdu Qubecmay deny my requestor recognitionof equivalenceof my diplomasand trainin;. The Ministrecle 'lnngration et des Communauts ulturelles and the Ordre des nfirmires a infirmiers du Qubecmay retain the nformation or documenB;. The Ministre e I'lmmigrationet desCommunauts ulturellesmay, f necessary nstitute egalproceedings gainstme for violating the aw by submittinfalse nformation or documents.xSignature Date

X

! declare that the nformailon and documents rovided in supportof my application or a comparativeevaluationof studiescompletedoutsideQubecand forrecognitionof equivalenceof diplomasand trainingby the Ordre des nfrmires t infirmiersdu Qubecare accurate'

Signature Date


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J-L ctrdroali dlnffrmlrr fi'ffi DtsctpLtNARy,UDIcIALANDPENALREcoRD

Name: Civenname(s):As it appears n birth certificate

lf you havebeenconvictedof a criminaloffence n Canada r another ountry unless ou haveobtaineda pardon,you mustdeclait to the Order.yo u mustalsodeclare isciplinary ecisionsendered y a Disciplinary ouncilof another rofessionalrder n Quebecor an eqvalentorganization utsideQuebec,andwhich lead o the revocation f the individual'spermit or equivalent), triking rom the Rothe limitationor restriction f the right o practise.ln addition, f you havebeenconvictedof a penaloffence, ou mustdeclare o the Order he penaldecisionshat concern, n parcular, he unlawfulpracticeof an exclusive rofession,he unauthorized seof a reserveditle (i.e. he useof a title or initials eserto the members f an order)andadvisingor encouraging omeoneo commitone of theseoffences-please nswer ll of the ollowingquestionsndreturn his orm assoonaspossible.

Haveyou beenconvictedof a criminaloffence n Canada r in anothercountry? YES NO tHaveyou beenconvictedof a disciplinary ffenceby anotherprofessionalrganizationn Canada rin another ountrY? YES r NO t

tHaveyou beenconvictedof a penaloffence elated o unauthorized seof a reserveditle orunlawiulpracticeof a professionn Canadaor in anothercountry? YES NO t

I declare hat he informationprovided s accurate nd truthful.

Signature Date

This orm and he documentsequiredmustbe retumeddirectlyto Bureaudu registraire,OllQ, 4200,boul. DorchesterOuegtWestmountQubec)Canada H3Z 1V4


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I, Jinky Manalili, authorize the following individual to serve, in my absence,as my representativeand to conduct businesson my behalf with all representatives f John Abbott College and I'Ordre desInfirmires et Infirmiers du Qubec.I authorize John Abbott College and l'Ordre des Infirmires et Infirmiers du Qubec to releaseinformation from my file or to conduct business in regards of my file with my designatedrepresentativeuntil I confirm you otherwise. This authorization s in accordancewith the Privacy Act.I am aware that any information which would be subject to exemption, if I had the right of accessunder the Privacy Act or the Access o information Act, will likely not be released.My representative's full name is: Roger Thauvette, living at 17627 boul. Gouin O., Montral,Qubec.H9J lB3 -514-624-6986.

Date:Jinky Manalili, BS in Nursing

I, Roger Thauvette, understand and accept that I am the person appointed by Jinky Manalili toconduct businesson her behalf with John Abbott College and l'Ordre des Infirmires et Infirmiers duQubec.

Date:Roger Thauvette

jinky copies of returning docs. feb. 26, 2012

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