SECTION 1

PERSONAL INFORMATION

I HEREBY SUBMIT THIS REVIEW OF QUALIFICATIONS FORM TO DETERMINE ELIGIBILITY FOR REGISTRATION/LICENSURE AS INDICATED BELOW:

I wish to practice in the area of: (PLEASE CHECK ONE)

* Family Practice

Specialty Practice Please indicate Specialty:

Other Please indicate Other:

* Surname:

* Given Names:

* Mailing Address:

* Telephone:

Fax:

* E-mail:

* Previously Applied: Yes No

Year:

* Do you currently hold a license elsewhere in Canada? Yes No

If Yes, please select Province/Territory:

If Yes, what type of license do you hold/held?

Are there any conditions or restrictions on that license? Yes No

If Yes, please list the conditions/restrictions as they appear on your license:

*	Family Practice
	Specialty Practice	Please indicate Specialty:
	Other	Please indicate Other:

* Surname:
* Given Names:
* Mailing Address:
* Telephone:
Fax:
* E-mail:
* Previously Applied:	Yes No
Year:

*	Do you currently hold a license elsewhere in Canada?	Yes No
	If Yes, please select Province/Territory:
	If Yes, what type of license do you hold/held?
	Are there any conditions or restrictions on that license?	Yes No
	If Yes, please list the conditions/restrictions as they appear on your license: