Name *

First Name

Last Name

Phone

(###)

###

####

Chinese Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Canadian Citizen or Permanent Resident according to Canada immigration Act *

Yes

No

Date of Issue

MM

DD

YYYY

Date of Expiration

MM

DD

YYYY

Date of Issue

MM

DD

YYYY

Date of Expiry

MM

DD

YYYY

Have you ever applied for a medical license, certificate of registration, or permit to practice and had the application denied, or rejected? *

Yes

No

Have you ever had a medical licence, certificate of registration, or permit to practice suspended, restricted, or revoked? *

Yes

No

Have you ever voluntarily surrendered your medical license, certificate of registration, permit to practice for any reasons other than avoidance or renewal fees? *

Yes

No

Have you ever, in expectation of, or during the pendency of an investigation/ disciplinary proceeding, voluntarily restricted your medical license, certificate of registration, or permit to practice? *

Yes

No

Have you ever been found guilty of professional misconduct or deemed incompetent/ incapacitated? *

Yes

No

Have you ever agreed to a settlement to avoid any proceeding or disciplinary action in respect to your professional conduct, competence, or capacity? *

Yes

No

Have you ever been charged with and/or convicted of a criminal offence? *

Yes

No

Are there any criminal charges pending against you? *

Yes

No

Has a court or governing body ever made a finding against you related to the practice of medicine (ie: malpractice, failure to honour confidentiality oath)? *

Yes

No

Have you ever been withdrawn from, suspended from, or expelled from a medical school? *

Yes

No

Have you ever been withdrawn from a post-graduate training program or been suspended/ removed from practice during a post-graduate training program? *

Yes

No

Are you now abusing, addicted to, or being treated for abuse/addiction to alcohol, narcotics and/or any other controlled substance? *

Yes

No

Is there any event, circumstance, condition or matter not disclosed on your answers to the preceding questions with respect to your character, conduct, competence, or capacity that may be an impediment to your application for membership with ADTCMRAC? *

Yes

No

Are you a member of/ applying to any other associations? *

Yes

No