Inspection Program - Inspection Deferral Request Form

Inspection Program - Inspection Deferral Request Form

IMPORTANT INFORMATION

Application Process

All inspection deferral requests must be made by completing this on-line Deferral Request form. The College must receive a request for a deferral by the designated Registrant within 14 days of notification of a pending inspection

Decision

All requests will be considered in a fair and objective manner by the Inspection Committee, and a determination will be based on each individual situation. The decision may be delayed, or the deferral request denied if there is insufficient information included with the request. In this situation, the designated Registrant will be notified in writing and may choose to provide further information.

PREMISES INFORMATION

Clinic Name*

Please provide the name of the registered premises.

Street Number and Name*

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

City, Town or Community*

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

Province or Territory*

Please select the Province or Territory for your mailing address.

Ontario

Postal Code*

Please provide the postal code for your mailing address.

DESIGNATED REGISTRANT INFORMATION

Designated Registrant Name*

Please enter the name of the Designated Registrant for this premises.

Designated Registrant Registration Number*

Please enter the registration number for the Designated Registrant.

INSPECTION AND DEFERRAL INFORMATION

Other Time Frame for Deferral*

Please specify the number of days you are seeking to defer this inspection.

Reason for Deferral*

Please indicate the reason a deferral is being requested.

Other details*

You have indicated that the reason for deferral is "other". Please provide the reason.

Deferral Reason Details*

Please provide a brief description of the reason(s) you are requesting a deferral.

Document Upload

Please upload any relevant documentation in support of your deferral request.

Drag and drop files here or

DECLARATION AND SIGNATURE

Declaration*

I hereby declare that, to the best of my knowledge, the information on this form is true and complete. I understand and agree that it is professional misconduct to make a false or misleading statement.

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.

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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