Guide to Applicants for Grandparented Registration

Binjiang Wu Ph.D/Prof/ Chief TCM Physician

// President, Ontario College of Traditional Chinese Medicine Chief, WFAMS Professionals Accreditation Agency in Canada Standing Director, World Federation of Chinese Medicine Societies (WFCMS)

Executive Member, the World Federation of Acupuncture & Moxibustion Societies (WFAS)(Non-Governmental Organization in Relation with WHO)

Registration Requirements, Grandparented Class

The requirements for registration are stipulated in Ontario Regulation 27/13, Registration, made under Traditional Chinese Medicine Act, 2006. 200627/13

According to Section 6, subsection (1) of O.Reg. 27/13: 61 6. (1) The following are nonexemptible requirements for a Grandparented certificate of registration:

1. The applicant must have completed a minimum of 2,000 traditional Chinese medicine patient visits in Canada, which may include traditional Chinese acupuncture patient visits, within the fiveyear period immediately before this paragraph came into force.
2000 2. The applicant must have submitted the completed application to the Registrar on or before the first anniversary of the day this paragraph came into force. 3. The applicant must have successfully completed the Safety Program that was set or approved by the Council or by a body that is approved by the Council for the purpose. 4. The applicant must have successfully completed the jurisprudence course set or approved by the Registration Committee.

(2) The requirements in paragraphs 3 and 4 of subsection (1) are not considered to have been met unless the applicant satisfies those requirements either within the threeyear period immediately before the date of that applicants application or at some point following the submission of his or her application but before the certificate of registration is issued. 134

Other requirements common to all classes of registration, including Grandparented certificate of registration are stipulated in Section 4 of O. Reg. 27/13. 27/134

To access the Ontario Regulation 27/13, Registration, made under Traditional Chinese Medicine Act, 2006, please visit the following link on elaws: http://www.elaws.gov.on.ca/html/regs/english/elaws_regs_130027_e.htm 200627/13 http://www.elaws.gov.on.ca/html/regs/english/elaws_regs_130027_e.htm

APPLICATION PROCESS
Step 1 Download the Grandparented Registration Application Form from the College website: www.ctcmpao.on.ca. OR Pick up a hard copy at our office. www.ctcmpao.on.ca

Step 2

Complete, Sign and Notarize your application (Incomplete information and/or missing signatures will cause delay.) / Read all instructions carefully before completing the form. All sections must be completed. Print legibly. Illegible applications will be returned. Check the title/designation you wish to apply. (See page 3 for details.) / Both you and your witness must sign the Validation Certificate to validate completion of 2,000 Patient visits within the past 5 years (on page 10 of the application form.) 200010 Sign the completed form before a Commissioner of Oaths, Notary Public or lawyer.

Prepare and attach all documents listed below to your application (Missing documents will cause delays.) Evidence of your identity Note: The name used in your practice and the name on your College Register must be the same. The College requires evidence of your identity. If the name on your documents is different from your current name, you must provide proof of your name change. Evidence of name change documents include: birth certificate, marriage certificate, divorce decree, passport, or validation of identity signed by legal counsel. --- A passportsize photo taken within the last 12 months; 112 The letter issued by the Registrar confirming your completion of the Jurisprudence Step 3 Course (test); The letter issued by the Registrar confirming your completion of the Safety Program (test); Your written language plan (if you took the Jurisprudence test with interpretation; or if you declared in the application that you are unable to speak, read, and write with reasonable fluency in English or French); Professional liability insurance certificate (if not available, submit within 30 days after registration has been approved.); 30 Criminal background check. For registration purposes, the College only requires a namebased criminal check.

Step 4 4

Submit TWO SEPARATE Certified Cheques or Money Orders payable to CTCMPAO for CTCMPAO 1. Application fee (nonrefundable) for $169.50 ($150 application fee + $19.50 HST); AND $169.50 ($150 + $19.50 ); 1. 201314 Registration fee for $960.50 ($850.00 registration fee + $110.50 HST). 2013-14$960.50 ($850.00 + $110.50). 1. The Registration fee will be returned if the application is not successful. Photocopy your application form and all attachments for your own record. Use the check list of information/documents to ensure that you have provided all information and required documents. /

Step 5 5

Step 6 6

Mail or deliver your application package to: Registrar College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario 163 Queen Street East, 4/F Toronto, Ontario M5A 1S1 Your application will be processed according to the time your application package arrives at the office. It will be processed within 36 weeks. Incomplete information, missing supporting documents, fees, or signatures will cause delay. 3-6

TITLE/DESIGNATION TO APPLY /
An applicant may wish to apply for one or both of the titles/designations described below. The College shall make the final decision on the title and designation to be awarded to an applicant depending on the experience and the documents he or she provides to support the application.

An applicant for the title Traditional Chinese Medicine Practitioner and designation R.TCMP is expected to:

have experience in TCM diagnosing and have provided treatments using TCM herbal and acupuncture therapies as evidenced in his or her 2,000 patient visits within the 5 years in Canada prior to application for registration; and 5 2000

Have successfully completed the Safety Program test for TCM Practitioner.

An applicant for the title Acupuncturist and designation R.Ac is expected to:

have experience in TCM diagnosing and have provided treatments using acupuncture therapies only as evidenced in his or her 2,000 patient visits within the 5 years in Canada prior to application for registration; and 5 2000

have successfully completed the Safety Program test for Acupuncturist.

Instructions

1. ALL applicants must complete this form and submit TWO SEPARATE certified cheques or money orders made payable to CTCMPAO CTCMPAO

One for the nonrefundable application fee for $169.50 ($150.00 application fee + $19.50 HST) and

$169.50 ($150.00 + $19.50 )

Another for the 201314 registration fee for $960.50 ($850.00 registration fee + $110.50 HST). 2013-14$960.50 ($850.00 + $110.50 ). The registration fee will be returned if the application is not successful.

2. To avoid delay in processing of your application, ensure that you:

complete all sections of the form that apply to you attach the required documents sign the application form attach your certified cheque /money order for payment to the College

3. If the College does not receive a completed application form with all required documents and certified cheques/money orders, the application form will not be processed.

4. Print your information on the application form legibly. Illegible forms will be returned. 5. Send or deliver your completed application form to:

Registrar CTCMPAO

163 Queen Street East, 4th Floor

Toronto, Ontario M5A 1S1

1. TITLE/DESGINATION /
An applicant may apply for one or both of the titles/designations described below. The Traditional Chinese Medicine Practitioner (R.TCMP) title denotes that an applicant can use both Traditional Chinese Medicine Practitioner and Acupuncturist titles and designations. The Acupuncturist (R. Ac) title denotes that an applicant can only use the Acupuncturist title and designation. / Check the box(es) applicable to you I am applying for Grandparented Registration to use the title/designation(s): / Traditional Chinese Medicine Practitioner (R. TCMP) Acupuncturist (R. Ac) The College shall decide on the title and designation to be awarded to an applicant depending on the experience and the documents he or she provides to support the application. (Refer to the Guide to Applicants for more information).

2. PERSONAL INFORMATION
Mr. Ms. Legal First Name Legal Last Name Legal Middle Name (if any)

Previous First Name (if different from legal name) ()

Commonly Used First Name (if different from legal name) ()

Previous Last Name (if different from legal name) ()

Commonly Used Last Name (if different from legal name) ()

Previous Middle Name (if different from legal name) ()

Commonly Used Middle Name (if different from legal name) ()

If more than one name is provided above, or if the name on any of your documents is different from your current name you must provide proof of name change. (See Guide to Applicants Step 3).

-3
The College requires evidence of your identity. If the name on any of your documents is different from your current name, you must provide proof of your name change. Examples of name change documents: birth certificate, marriage certificate, divorce decree, passport or validation of identity signed by legal counsel.

Document attached OR Signature ______________________________________________ A Commissioner of Oaths, Notary Public, Lawyer (Official seal/stamp or business card must be provided)( ) Preferred name to be used on Certificate of Registration and on College Register Legal Name Commonly Used Name Both The name that you choose to be put on the Certificate of Registration and on the College Register must be the name that you use in your practice. Date of Birth (mm/dd/yyyy) // / / / Gender

3 CONTACT INFORMATION
Home Address Street No. & Name Apt/Suite No. City/Town Email Province Postal Code Tel Country Fax

Primary Business Address Street No. & Name

Apt/Suite No.

City/Town Email

Province

Postal Code Tel.

Country Fax

Secondary Business Address Street No. & Name

Apt/Suite No.

City/Town Email

Province

Postal Code Tel

Country Fax

Choose one address for your mailing address Secondary Business

Home 1

Primary Business 2

Note that your business address information is available to the public. If you provide your home address as your business address, it will be available to the public.

4 PHOTO
One photograph must be full faced, of passport size and quality, taken within 12 months of submitting the application. 12 My photograph attached here was taken on : ______/_____/___________/ _________________________ (mm/ dd / yyyy ) Signature

Paste a passport-size Photo here

Photo ID is required for registration verification and walletsized Photo ID purposes. Be advised that when you resign as a member of the College your photo will be destroyed unless the photo is required for regulatory purposes. For more information, refer to the Registration Policies on Photo Destruction available on our website at www.ctcmpao.on.ca.

www.ctcmpao.on.ca.

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5COMPLETION OF JURISPRUDENCE COURSE (TEST)

Check the box(es) applicable to you.

Yes, I have successfully completed the College Jurisprudence Course (test). Date completed __________________ (please specify ) ______/_____/___________/ (mm / dd / Language of Test yyyy )

If yes, attach a copy of the letter confirming the completion of the College Jurisprudence Course (test).
No, I will be taking the College Jurisprudence Course (test) on ______/_____/___________/ (mm/ dd / yyyy ) Note that the College Jurisprudence Course is to be completed either within the 3year period immediately before the date of this application or at some point following the submission of this application, but before the certificate of registration is issued. Jurisprudence Course (test) results are valid for only 3 years after the date on your confirmation letter issued by the College. 3 3

6COMPLETE OF SAFETY PROGRAM (TEST)

Check the box(es) applicable to you.

Yes, I have successfully completed the College Safety Program to pursue R.TCMP designation on ___/_____/_____/ (mm/ dd/ yyyy)
Yes, I have successfully completed the College Safety Program to pursue R.Ac designation on ___/_____/_____/ (mm/ dd / yyyy) If yes, attach a copy of the letter confirming the completion of the College Safety Program (test). No, I will be taking the College Safety Program (test) on (mm/ ______/_____/___________/ dd / yyyy )

Note that the College Safety Program is to be completed either within the 3year period immediately before the date of this application or at some point following the submission of this application, but before the certificate of registration is issued. Safety Program (test) results are valid for only 3 years after the date on your confirmation letter issued by the College. 3 3

7 LANGUAGE FLUENCY
Check the box(es) applicable to you. a) Are you able to speak, read, and write with reasonable fluency in English so that you can offer professional services to patients in that language? b) Are you able to speak, read and write with reasonable fluency in French so that you can offer professional services to patients in that language? Yes No

Yes

No

c) Additional languages in which you can personally and competently provide professional services. (Provide up to 5 as applicable.) 5 1. _____________________ 3.________________________ 4. _____________________ 2. ____________________ 5. ____________________

If you have indicated that you are unable to speak, read, and write with reasonable fluency in either English or French to offer professional services to patients, submit a written plan demonstrating how you will effectively communicate with patients and the health care system either in English or French. For more information, refer to the Registration Policies on Written Language Plan available on our website at www.ctcmpao.on.ca.

www.ctcmpao.on.ca.

8 REGISTRATION TO PRACTISE TRADITIONAL CHINESE MEDICINE PROFESSION IN CANADA OR OTHER COUNTRY OR STATE WHERE YOU PREVIOUSLY WORKED (If not applicable, enter N/A) N/A

List any licence or registration that you hold or held to authorize you to work as a Traditional Chinese Medicine Practitioner and/or Acupuncturist in a country, province, or state where you work or previously worked. Licence/Registration / Organization/Association/ Province/State/ Country

Licence/Registration /

Organization/Association/

Province/State/

Country

Licence/Registration /

Organization/Association/

Province/State/

Country

Attach a copy of all licences or certificates of registration as a Traditional Chinese Medicine Practitioner and/or Acupuncturist. /

9MEMBERSHIP WITH PROFESSIONAL ASSOCIATION OF TRADITIONAL CHINESE MEDICINE AND ACUPUNCTURE (If not applicable, enter N/A) N/A
Organization Name 1 -1 Certification /identifier # ______________________ from ______/_____/_______/ to ______/_____/_______/ / (mm/ dd /yyyy ) (mm/ dd /yyyy ) Organization Address Street No. & Name 1 Apt/Suite No.

City/Town Email

Province

Postal Code Tel. ______/_______/_______/ (mm/ dd /yyyy )

Country Fax

Official position(s) held (specify title and duration, if applicable) Organization Name 2 -2

Certification /identifier # ______________________ from ______/_____/_______/ to ______/_____/_______/ / (mm/ dd /yyyy ) (mm/ dd /yyyy ) Organization Address Street No. & Name 1 Apt/Suite No.

City/Town

Province

Postal Code Tel. ______/_______/_______/

Country Fax

22

Email Official position(s) held (specify title and duration, if applicable)

10.

WORK HISTORY/PRACTICE EXPERIENCE AS A TRADITIONAL CHINESE MEDICINE PRACTITIONER AND/OR ACUPUNCTURIST IN CANADA //

You must provide evidence that within the last 5 years you have practiced the profession as a Traditional Chinese Medicine Practitioner and/or Acupuncturist. 5/ You are required to provide your work history as a Traditional Chinese Medicine Practitioner and/or Acupuncturist within the last 5 years in Canada, from ______ /_____ /______ / to _____/______ /_____ / 5/ __/___/_____/___/___ Practice Experience in Canada Start Date of End Date of Employer or Facility Employment Employment Name (mm/dd/yyyy) (mm/dd/yyyy) // // _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / _____/______ /____ / Employer or Facility Address Employer/ Facility Phone Number (xxx)xxxxxx (xxx)xxxxxx (xxx)xxxxxx (xxx)xxxxxx (xxx)xxxxxx

If necessary, attach additional pages to describe your work history/practice experience. / You will be required to provide evidence of having completed a minimum of 2,000 traditional Chinese medicine patient visits in Canada within the last 5 years. You must complete the Validation Certificate on the following pages with respect to the 2,000 traditional Chinese medicine patient visits, listing all of the traditional Chinese medicine diagnoses and treatments that you have performed as a Traditional Chinese Medicine Practitioner and/or Acupuncturist in Canada within the past 5 years. 520002,000 / You must sign the Validation Certificate of traditional Chinese medicine patient visits to state that the information is true.

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Validation Certificate Respecting Traditional Chinese Medicine Patient Visits

Provided below are common disorders that Traditional Chinese Medicine Practitioners and/or Acupuncturists have knowledge, skill and judgement to diagnose and treat. / On the chart below, provide as evidence an estimate of your patient visits within the last 5 years in Canada by checking off the conditions under each disorder that you have diagnosed and treated in your practice 5 from _____/______ /____ / to _____/______ /____ / (mm/ dd / yyyy) (mm/ dd / yyyy) Patient visit refers to every treatment provided to a patient after initial TCM diagnosis using either herbs only, or acupuncture only, or a combination of both.

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Disorders

TCM Diagnosis Estimated Number of Patient Visits for TCM HERBAL MEDICINE ONLY Yes No

Estimated No. of patient Visits for ACUPUNCTURE ONLY (Including Tuina, Cupping & Moxibusti on, etc.)

Estimated No. of Patient Visits for patients who received BOTH TCM Herbal Medicine and Acupuncture

Respiratory Disorders Gan Mao Common Cold & 1 Flu 2 Ke Sou Cough

Xiao Chuan Wheezing & Asthma/Breathless Digestive Disorders

Digestive Disorders Wei Wan Tong 4 Epigastric Pain/Gastralgia 5 Tu Suan : Acid Reflux 6 Cao Za : Gastric Upset Fu Tong : Abdominal 7 Pain/Colitis 8 Xie Xie : Diarrhea 9 Bian Mi : Constipation 10 Xiao Ke : Diabetes 11 Ou Tu : Vomiting

25

Pain/ Neurological Disorders / Bi ZhengPainful Obstruction Syndrome/Arthritis Mian Tong : Facial Pain/Trigeminal Neuralgia Yao Tong Lumbago/Sciatica Lao Zhen Neck Sprain/Stiff Neck Niu Shang : Sprains Mian Tan :Facial Paralysis/Bells Palsy Tou Tong Headaches Xie Tong Hypochondria Pain Xuan Yun Dizziness/Vertigo Zhong Feng Stroke Jue Zheng Syncope Wei Zheng Atrophy Syndrome

12

13

14 15 16 17 18 19 20 21 22 23 26

Urinary/Genital Disorders / 24 25 26 Shui Zhong Edema Long Bi Urine Retention Yang Wei : Impotence

Gynaecological & Obstetric Disorders

Yue Jing Qian Hou Zhu Zheng Menstrual Syndromes (including PMS) Tong Jing Dysmenorrhea/PID Yin Yang Vaginitis/Itching Yue Jing Bu Tiao Irregular Menstruation Ren Shen E Zu Morning Sickness Jue Jing Qian Hou Zhu Zheng Menopausal Syndrome Jing Bi : Amenorrhea Bu Yun Infertility Beng Lou Abnormal Uterus Bleeding (including endometriosis)

27

28 29 30 31

32
33 34

27 35

Cardiovascular Disorders 36 Jing Ji : Palpitations

Psychiatric/Mental Disturbances/ 37 38 Yu Zheng : Anxiety/Depression/Stress Bu Mei : Insomnia

Skin Disorders/Infections / 39 41 Shi Zhen : Eczema Huang Dan : Jaundice Chan Yao Huo Dan /She Chuan Chuang Herpes Zoster

42

Disorders of Sense Organs 43 44 45 46 47 48 Er Long : Deafness Er Ming : Tinnitus Er Tong : Earaches Jin Shi : Myopia Bi Yuan : Sinus Infection Yan Hou Zhong Tong : Sore throat Ya Tong : Toothache

28 49

Pediatric Disorders 5 0 Gan Ji Indigestion for Children

Blood Disorders Cancer Other 5 1 5 2 Xu Lao : Tiredness/Fatigue Zhi Chuang : Hemorrhoid

29

Total: 2,000 TCM patient visits 2,000 Validation of Traditional Chinese Medicine Patient Visits

GRAND TOTAL:_______________ Yes No

"I hereby certify that I have been trained to perform, am competent to perform and have performed in my employment the specific treatments and diagnoses set out above, within the time frame indicated. I hereby certify that I have completed a minimum of 2,000 traditional Chinese medicine patient visits within the past 5 years. I understand that providing false or misleading information about my patient visits is grounds for denying or revoking my registration". 2,000

_____________________________ Applicants Signature

_____________________________ Witness Signature

________________________ Print Name

________________________ Print Name

_______________________ Date Signed

_______________________\ Date Signed

Be advised that the College reserves the right to contact you and your employer for clarification regarding your employment history and patient visits listed on this Validation Certificate respecting traditional Chinese medicine patient visits that you have completed and signed.

30

11. PROFESSIONAL LIABILITY INSURANCE

I confirm that I shall comply with the Colleges required professional liability insurance coverage as specified in the Bylaws of College. Check ONE of the following two boxes I agree to submit the insurance certificate to the College within 30 days after my registration has been approved. 30 I have attached the certficate of professional liability insurance. For more information, refer to the Registration Policies on Professional Liability Insurance available on our website at www.ctcmpao.on.ca. www.ctcmpao.on.ca.

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12. DECLARATION OF CONDUCT

a) Have you ever been found guilty of any noncriminal offence that resulted in a fine of over $1,000 or any form of custody or detention or had a finding of guilt for a criminal offence in Ontario or in any other jurisdiction in or outside Canada? $1,000 b) Has there ever been a finding of professional negligence or malpractice against you? c) Has there ever been any finding of professional misconduct, incompetence or incapacity, or similar finding against you by any regulatory body in Ontario or in any other jurisdiction? d) Is there currently a proceeding against you involving an allegation of professional misconduct, incompetence or incapacity, or any similar proceeding by any regulatory body in Ontario or in any other jurisdiction? e) Have you ever made an application for registration as a Traditional Chinese Medicine Practitioner and/or Acupuncturist in any other jurisdiction that was refused? / f) Have you ever had an application for registration rejected by a regulatory College in Ontario or in another province?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

32 g) Have you ever been unsuccessful in an attempt to pass a registration examination for
a regulated health profession in Ontario or in another jurisdiction? Yes No

h) Has there ever been a court proceeding brought against you alleging that you held yourself out as, or practising as a regulated health professional without being so registered? i) Do you currently suffer from any physical or mental condition or disorder which may impair your ability to practise traditional Chinese medicine safely and competently and which, if left untreated, would impair your ability to practise traditional Chinese medicine safely and competently?

Yes

No

Yes

No

NOTE: If you answer yes to question i), provide a detailed explanation and arrange for your treating regulated health professional(s) to send directly to the College a report on your condition or disorder setting out your diagnosis, course of treatment and current health prognosis. Where appropriate, this report should indicate any accommodation(s) that your regulated health professional deems necessary in order for you to practise in a safe manner. i) The College might require further information from your past and/or present treating regulated health professional and will contact him or her, if necessary. / In submitting this form, you are providing your authorization to your past and/or present treating regulated health professional to disclose further information to the College. /

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j) If you were registered with a body responsible for the regulation of a profession, and you ceased being registered, were you in good standing, (i.e., all fees paid, all information provided, no outstanding investigations, proceedings or sanctions) at the time you ceased being registered? If no, provide details. k) If you are a member of a regulated profession, did you ever fail to comply with any obligation to pay fees or provide information to the regulator? l) If you are a member of a regulated profession, has an investigation by the regulator ever been initiated in respect of you? m) If you are a member of a regulated profession, has the regulator ever imposed a sanction on you? n) Is there any other event that would provide reasonable grounds that you will not practise traditional Chinese medicine in a safe and professional manner?

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

34

If you answer yes to any of the above questions (with the exception of j), provide full details and attach copies of all relevant documents. j If your answer to any of the above questions changes following your submission of the application, but before any issuance of a certificate, you must immediately advise the College and provide written details with respect to any change. I have attached a criminal background check using the Canadian Police Information Centre (CPIC) database issued on ______ /______ /_______ / (mm/ dd / yyyy ) and by _________________________ (Specify OPP or municipal police service in Canada)

For more information, refer to the Registration Policies on Criminal Background Check available on our website at www.ctcmpao.on.ca. www.ctcmpao.on.ca

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13. HEALTH PROFESSION DATABASE

The Ministry of Health and LongTerm Care and the College are working together to learn more about your profession by collecting demographic, geographic, educational, and employment information. This data collection is part of HealthForceOntario, the province's health human resources strategy. Your answers to these questions will help the Ministry develop policies and programs that address supply and distribution, education, recruitment and retention for your profession. - All of Ontario's 80,000 regulated allied health professionals are providing this information as part of their annual registration and renewal process. To protect your privacy, the data we submit to the Ministry will be anonymous. You are required to provide this information under the Regulated Health Professions Act, 1991. The reliability of the information we receive and the quality of the decision making that follows depends on you. By completing this form accurately and thoroughly, you will help ensure that Ontarians have access to the services of your profession, when and where they need them. 80,000 1991

36

Concurrent registration Check the box(es) applicable to you. I am currently registered to practice traditional Chinese medicine in countries other than Canada If yes, provide up to three countries where you are currently registered to practice the traditional Chinese medicine profession. 1. __________________________ 2. ___________________ 3. _________________________

Provinces/territories or states other than Ontario where you are currently registered to practise (Select up to 3) /3 Alberta British Columbia Manitoba Other Newfoundland Nova Scotia Northwest Territories State(s) in USA Nunavut Prince Edward island New Brunswick 1. _________________ Quebec Saskatchewan Yukon Territory 2. _________________ 3. _________________

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Practice history If you previously practised outside of Canada, indicate the country where you practised most recently OR If you previously practised outside of Ontario but within Canada, indicate the province/ territory where you practised most recently / ___________________________________________ (Province/Territory) /

________________________________________ (Country)

If USA, specify the state _____________________________________________ Last year in which you practised in the most recent location other than Ontario ___________________________ (year)

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Education related to traditional Chinese medicine Indicate all education related to the traditional Chinese medicine profession (e.g. diploma, doctorate, baccalaureate, master, professional doctorate, other.) Degree Institution of Graduation Province/State/ Country Year of Graduation 1. 2. 3. 4. 5. Education NOT related to traditional Chinese medicine qualifications Highest level of education completed that was unrelated to traditional Chinese medicine qualifications Diploma Baccalaureate Masters Doctorate Professional Doctorate Other Field of study for highest level of education completed that is NOT related to traditional Chinese medicine qualifications General Rehabilitation Science Mathematics, Computer Information Sciences Medical Laboratory Science Health Administration/Management Public Administration Kinesiology and Exercise Science Public Health Health Professions and Related Clinical Sciences Gerontology Biological and Biomedical Sciences Psychology Social Sciences, Arts and Humanities Physical Sciences Business, Management, Marketing and Related Education Law Engineering Other Field of Study Country of Graduation Canada USA

Other (Specify)()_______________________ Province/Territory, if education completed in Canada__________________ / State(s) if education completed in USA _______________________

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Year of Graduation___________

Employment Is this the first time you will practise the traditional Chinese medicine profession?

Yes

No

If no, in which country and year did you first begin to practise in the traditional Chinese medicine profession? _________________________ ________________________________ (Country) (year) If the country where you first practised the traditional Chinese medicine profession was Canada or the USA indicate province/territory or state. / Alberta British Columbia Manitoba Other Newfoundland Nova Scotia Northwest Territories State(s) in USA Nunavut Prince Edward island New Brunswick 1. _________________ Quebec Saskatchewan Yukon Territory 2. _________________ 3. _________________ If the country where you first practised the traditional Chinese medicine profession was not Canada provide the first Canadian location of practice in the profession. Alberta British Columbia Manitoba Newfoundland Nova Scotia Northwest Territories Nunavut Prince Edward island New Brunswick Quebec Saskatchewan Yukon Territory Ontario In which year did you first begin to practise the traditional Chinese medicine profession in Canada? ____________________ (year)

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14. APPLICANTS DECLARATION

I_____________solemnly declare that the contents of this application including all attachments are true and complete to the best of my knowledge and belief. ___________ I understand and agree that if I make any false or misleading statement or representation on or in connection with my application, I shall be deemed not to have satisfied the registration requirements for a Certificate of Registration. I further understand and agree that if the Certificate of Registration should be issued to me based upon any false or misleading statement or representation, the Certificate of Registration can be immediately revoked and I may face disciplinary proceedings. I acknowledge that the information provided on this form is used by the College to administer the Regulated Health Professions Act, 1991, the Traditional Chinese Medicine Act, 2006, the Regulations under these Acts, the Bylaws, policies, Standards of Practice and programs related to the governance of the profession; and that the information is collected, used and disclosed in accordance with the Health Professions Procedural Code and the College Bylaws. 19912006 I understand that I must notify the Registrar in writing within thirty days of any change of location of practice or employment, business name of practice, home and mailing addresses, phone number, and email address.

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I authorize the College to obtain information from other regulatory bodies, educational institutions, present and former employers, referees, any of my past and/or present treating regulated health practitioners, and any other sources for the purposes related to my application for registration, including any experience and qualifications. //

I authorize my past and/or treating regulated health practitioners to disclose personal health information to the College for the purposes related to my application for registration. /
Taken and declared before me in the() _____________________ _____________________ City/Town (/) _______________________

Province/State/

Country ()
of

This ________________________________day ________________________________________20_____ Signed______________________________________ Applicant__________________

Signature of

Commissioner of Oaths, Notary Public, Lawyer (Official seal/stamp or business card must be provided) ()

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For Grandparented Registration

Attached a certified cheque or money order made payable to CTCMPAO for $169.50; AND $169.50 Attached a certified cheque or money order made payable to CTCMPAO for $960.50 $960.50 Selected the title/designation to apply / Provided evidence of identity (e.g. birth certificate, passport, marriage certificate, divorce decree or a validation of identity signed by legal counsel.)

Provided preferred name to be used for Certificate of Registration and on the Register
(Note: the name you use in your practice and your name on the College register must be the same. Follow instructions on section 2 of the application, if your practice name is different from your legal name.)

Provided business address

Attached passport size photo taken within last 12 months Attached letter confirming completion of Jurisprudence Course Attached letter confirming completion of Safety Program

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 Attached written language plan if indicated that you are unable to read and write with reasonable fluency in either English or French to offer professional services to patients. Attached copy of certificate of registration or licences to practise traditional Chinese medicine profession in Canada or other Country or State where you have previously worked, if applicable Provided membership information with professional TCM association, if applicable Completed information on work history/practice experience in Canada within the last 5 years / Completed Validation Certificate on 2,000 traditional Chinese medicine patient visits within the last five years; and Signed and Witnessed the Validation Certificate 2,000 Attached professional liability insurance (if available, if not, submit within 30 days after registration has been approved) 30

Answered all questions on declaration of conduct Attached report on criminal background check

Answered all questions on Health Profession database (required by the Ministry of Health and LongTerm Care)
Applicants declaration signed and validated by Commissioner of Oaths, Notary Public, Lawyer ,,

THANK YOU!