IVIT Examination Pre-Registration Form (Non-Registrants)

IVIT Examination Pre-Registration Form (Non-Registrants)

This form is required for non-Ontario NDs, in order to set-up a College user account to allow access to the online exam registration portal for the Ontario Intravenous Infusion Therapy exam. Please ensure that you meet exam eligibility criteria, as noted in the Ontario Intravenous Infusion Handbook, before submitting documentation to the College.

CONTACT INFORMATION

First Name*

Please provide your given (first) name.

Last Name*

Please provide your family (last) name.

Email*

Please provide an email address to which the College may send you communication or information.

Telephone*

Please provide a telephone number where the College can reach you during regular business hours. To adjust the country, please use the arrow key to select the correct flag.

Phone

CONFIRMATION OF IDENTITY

Government ID*

All Exam Pre-registration forms must include a copy of valid (not expired) government issued photo identification, clearly showing full name, date of birth, face and signature. Only the identification listed below is accepted by the College at this time. Please indicate which identification you are providing.

Please note: ID used must have a photo and your signature. The Secure Certificate of Indian Status Card must have been issued on or after December 15, 2009.

Supporting Documents*

Please upload a copy of the photo identification that you listed above.

Drag and drop files here or

NATUROPATHIC REGISTRATION (NON-ONTARIO)

Regulatory Authority*

Please select the name of the Regulatory Authority in the Canadian province in which you are registered as a Naturopathic Doctor.

College of Naturopathic Doctors of Alberta

College of Naturopathic Physicians of British Columbia

Manitoba Naturopathic Association

Saskatchewan Association of Naturopathic Practitioners

Registration Number*

Please enter your registration number with the Regulatory Authority you identified above.

DECLARATIONS AND SIGNATURE

Exam Registration Eligibility Declaration*

I declare that I am currently registered to practise naturopathy in a Canadian jurisdiction other than Ontario and that I am in good standing with the Regulatory Authority in that jurisdiction.

I agree

I do not agree

Truthful & Complete Declaration*

I declare the contents of this application are true and complete to the best of my knowledge and belief. I understand and agree that if I make a false or misleading statement or representation on this form, the College reserves the right to deny my exam registration for the Ontario Intravenous Infusion Therapy examination.

I agree

I do not agree

Signature

By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.

I voluntarily sign this form and affix my digital signature.*

Pre-registration Date*

Please enter the date you are submitting this pre-registration form.

COPY OF SUBMISSION

Below is a check box to enable you to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address. This will enable the on-line system to send you a copy of the information that you have provided to the College.

Send me a copy of my responses

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