Extension Request for Peer and Practice Assessment

This form is used by Registrants of the College of Naturopaths of Ontario who are requesting an extension for the date by which a peer and practice assessment is to be completed.


Application Process


All extension requests must be made in writing by completing this form. Applications for extensions must be received within 30 days of being notified of your selection to participate in a peer and practice assessment, unless there are mitigating factors that prevent you from submitting the request within this time frame.


You may submit an extension request if you are currently on parental leave, are seriously ill, are on a leave of absence, or if there are other extenuating circumstances. Extension requests should include supporting documentation, where applicable, that would assist the College in making its decision. Some examples of supporting documents may include medical certificates, notes or letters to support a medical reason for the request, letters from other sources or persons, or any other documentation that is relevant to the request.


Decision


The Quality Assurance Committee will consider all requests in a fair and objective manner and will make a determination based on your individual situation. Please submit your request as far in advance as possible, to give the Committee sufficient time to review the request and make a decision. The decision may be delayed, or the extension request denied if there is insufficient information included with the request. In this situation, you will be notified in writing and may choose to provide further information.


You will be notified in writing once the QA Committee has made a decision regarding your extension request. If an extension request is granted and you require an additional extension, you will be required to submit a new request.

REGISTRANT INFORMATION

Please provide your first (given) and last (family) name.

Please enter your four-digit College registration number.

Please provide the name of your clinic (if applicable).

Please provide your street number and street name, or postal box number for your mailing address.

Please provide the city, town or community for your address.

Please select the Province or Territory for your address.

Ontario
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Please provide the postal code for your address.

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

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

EXTENSION REQUEST DETAILS

Please enter the length of time (in days) of your extension requested (e.g. 30 days, 90 days, etc.).

Extension Reason*

Please select the reason for your request.

Please specify the other reason for your extension request.

Please provide a description of the reason(s) you are requesting an extension.

Please upload any relevant documentation (e.g. medical certificates, letters, etc.,) that supports your request and would assist the Quality Assurance Committee in making its decision.

Drag and drop files here or

DECLARATIONS AND SIGNATURE

Declaration*

I hereby declare that, to the best of my knowledge, the information on this request form is true and complete. I understand and agree that if I make a false or misleading statement, the Quality Assurance Committee may deny my request for an extension without further consideration of the request.

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.

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.

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