Form D - Educational Credential And Qualifications Assessment Document Request Form (Page 2 of 4) in pdf

Form D - Educational Credential And Qualifications Assessment Document Request Form Page 2

1243 Islington Avenue, Suite 501

Toronto, Ontario M8X 1Y9

P : 416 234 8800 | F : 416 234 8820

Form D– Document Request Form

The physiotherapy institution must complete this section. Please use more paper if necessary.

This form must be completed by a program official such as a Registrar, Program Director, Program Dean, or Principal

Name of Person Completing the Form (Print)

Title

Date

School Seal/Stamp

Signature

Full Name of Student:

Date of birth:

day month

year

Male

Female

Student ID Number:

Name of physiotherapy (PT) institution:

Name of University if different from above:

Address of PT institution:

Telephone #:

Fax #:

Email address:

Name of degree, diploma or certificate awarded:

In native language:

Minimum academic entrance requirement for the program:

Student’s mode of entry/entrance data/ entrance qualifications (if different from above):

Admission date:

Completion date (including clinical practice):

Length of physiotherapy program (you just need to complete one): Number of Years

Number of Semesters:

Form D - Educational Credential And Qualifications Assessment Document Request Form Page 2