Labour Mobility Application Form - Alberta College of Paramedics

Labour Mobility Application FormApplicants approved through the Agreement on Internal Trade shall have one year to successfullycomplete the Jurisprudence Exam AND complete the registration process. Failure to complete theJurisprudence Exam and registration process within one year will result in the applicant having toresubmit the Labour Mobility Application and the Verification of Registration to the College for approval.Part A – Personal informationLast Name/Family Name First/Given Name Middle NameSocial Insurance Number Date of Birth (mm/dd/yy) E-mail AddressAddress:City Province Postal CodePhone Number (Home) Phone Number (Business) Phone Number (Cell)Have you ever been convicted of a criminal offense or do you have outstanding charges? Yes:No:Part B – Other professional experience since date of graduation from training programDateStart Finish Status(mm/dd/yy) (mm/dd/yy) Position (FT/PT/Casual) Name of EmployerPart C – Post basic courses since graduation (i.e. Pulse Oximetry, Glucometric Testing)DateOriginal CertificateStart Finish Attached(mm/dd/yy) (mm/dd/yy) Name of Course Agency/Educational Institution (will be returned)_______________________________________________________________________________________________________Alberta College of Paramedics 1 April 1, 2009Labour Mobility

Part D – Registration status & paramedicine experience – Complete all questions (N/A if not applicable)Where did you first obtain licensure? Level Province Date (mm/dd/yy)1. In what province are you currently practicing?2. In what other province(s) have you obtained licensure? List all.3. Have you been registered with any other health profession(s)?(if yes, attach an explanation)4. Is there any reason that you may not be fit to engage in paramedicine practice? Yes: No:5. Is your paramedic conduct or practice currently under investigation? Yes: No:6. Have you ever been denied registration? Yes: No:7. Have you been disciplined by a professional regulatory body? Yes: No:8. Has your registration ever been revoked or suspended or had conditions attached? Yes: No:Information for each paramedicine employer you have had in the last yearDate (mm/dd/yy) Employer Contact Information Primary areaofStart Finish Name Phone Number ResponsibilityPaymentFees: $50 Jurisprudence Exam$100 Administration fee (NON-REFUNDABLE)TOTAL: $150 (payable to Alberta College of Paramedics)Credit Card Money Order Cash Certified ChequeVisa / MasterCard Payment Authorization:Name of Cardholder:Signature of CardholderCredit Card #Expiry Date (mm/yy)Name of Member (if different than cardholder)Amount to be billed to credit card: $150.00I certify that the information contained in this form is true and correct._____________________________________________Applicant’s Signature________________________DatePersonal information on this form is collected by the Alberta College of Paramedics under the authority of the Health Disciplines Actand the EMT Regulation and according to the Agreement on Internal Trade. This information may be used to issue a registrationcard for purposes of employment in the Province of Alberta. If you have any questions about the collection of this information,please contact the Registrar, Alberta College of Paramedics. This information is protected from unauthorized use and disclosure inaccordance with the Alberta Personal Information Protection Act (PIPA) and College Policy._______________________________________________________________________________________________________Alberta College of Paramedics 2 April 1, 2009Labour Mobility Application